What is the advice regarding it?

From the Guidelines

The advice regarding hypertension management is to prioritize lifestyle modifications and evidence-based pharmacological interventions to achieve optimal blood pressure control, as outlined in the 2017 American College of Cardiology/American Heart Association hypertension guideline. When managing hypertension, it is essential to identify and address contributing lifestyle factors, such as diet, physical activity, and substance use, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. The treatment of resistant hypertension should include maximization of diuretic therapy, addition of a mineralocorticoid receptor antagonist, and referral to a hypertension specialist if blood pressure remains uncontrolled, as suggested by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. Additionally, a team-based care approach, use of electronic health records, and patient registries can be beneficial in recognizing uncontrolled hypertension and guiding initiatives for quality improvement in hypertension control, as recommended by the 2017 American College of Cardiology/American Heart Association hypertension guideline 1. In terms of specific pharmacological interventions, the use of blockers of the renin-angiotensin-aldosterone system, such as angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin antagonists (sartans), has been shown to be effective in reducing mortality and slowing down the progression of diabetic chronic kidney disease, as suggested by the 2018 study on perioperative management of adult diabetic patients 1. However, the most recent guideline on the management of chronic coronary syndromes, published in 2024, recommends a multidisciplinary approach to help patients achieve healthy lifestyles, in addition to appropriate pharmacological management, and emphasizes the importance of aerobic physical activity and reduction in sedentary time 1. Overall, the management of hypertension requires a comprehensive approach that takes into account lifestyle modifications, pharmacological interventions, and team-based care, with the goal of achieving optimal blood pressure control and reducing the risk of cardiovascular complications. Key considerations include:

• Identifying and addressing contributing lifestyle factors
• Maximizing diuretic therapy and adding a mineralocorticoid receptor antagonist in cases of resistant hypertension
• Using blockers of the renin-angiotensin-aldosterone system, such as ACE inhibitors and sartans
• Implementing a team-based care approach and using electronic health records and patient registries to guide quality improvement initiatives
• Encouraging aerobic physical activity and reduction in sedentary time
• Considering home-based cardiac rehabilitation and mobile health interventions to increase patients' long-term adherence to healthy behaviors.

From the FDA Drug Label

Advise the patient to read the FDA-approved patient labeling (Patient Information). Lactic Acidosis: Explain the risks of lactic acidosis, its symptoms, and conditions that predispose to its development Advise patients to discontinue metformin hydrochloride tablets immediately and to promptly notify their healthcare provider if unexplained hyperventilation, myalgias, malaise, unusual somnolence or other nonspecific symptoms occur Counsel patients against excessive alcohol intake and inform patients about importance of regular testing of renal function while receiving metformin hydrochloride tablets. The advice regarding metformin hydrochloride tablets is to:

• Read the FDA-approved patient labeling
• Be aware of the risks of lactic acidosis and its symptoms
• Discontinue the medication and notify the healthcare provider if symptoms occur
• Avoid excessive alcohol intake
• Undergo regular testing of renal function 2

From the Research

Advice Regarding Antihyperglycaemic Agents and Antihypertensive Therapy

• The management of type 2 diabetes mellitus usually involves combined pharmacological therapy to obtain adequate glucose control and treatment of concurrent pathologies, such as dyslipidaemia and arterial hypertension 3.
• Drug-drug interactions must be carefully considered with antihyperglycaemic drugs, especially when combining sulphonylureas, meglitinide derivatives, metformin, and thiazolidinediones 3.
• The combination of metformin and antihypertensive therapy with drugs blocking the renin angiotensin system, such as ACE inhibitors or ARBs, can be life-threatening under certain circumstances, such as acute renal failure and dehydration 4.
• General advice should be given to patients regarding reduction of dosage or withdrawal of the drugs during acute intercurrent illness with dehydration to prevent metformin-associated lactic acidosis 4.
• ACE inhibitors are commonly prescribed medications for the management of hypertension and other chronic conditions, including heart failure and chronic kidney disease, but may have a higher risk of bradykinin-mediated side effects like angioedema and cough compared to ARBs 5.
• Recent evidence has suggested that ARBs may have neuroprotective effects compared to other antihypertensives, including ACE inhibitors, but this warrants further study 5.
• ACE inhibitors may provide a special advantage in addition to blood pressure control for patients with type 2 diabetes, but conclusive evidence on the comparative effects of antihypertensive treatments will come from large prospective randomized trials 6.

Key Considerations for Patients with Type 2 Diabetes

• Patients with type 2 diabetes should be aware of the potential risks and benefits of combining antihyperglycaemic agents and antihypertensive therapy 3, 4.
• Patients should be advised to reduce dosage or withdraw drugs during acute intercurrent illness with dehydration to prevent metformin-associated lactic acidosis 4.
• Patients should be monitored closely for signs of bradykinin-mediated side effects, such as angioedema and cough, when taking ACE inhibitors 5.
• Patients should be informed of the potential benefits and risks of ACE inhibitors and ARBs, and should discuss their individual treatment options with their healthcare provider 5, 6.