From the Guidelines
The pharmacological protocol for managing hypertension in patients with diabetes should include prompt initiation and timely titration of pharmacologic therapy, with a first-line treatment of an ACE inhibitor or angiotensin receptor blocker, at the maximally tolerated dose indicated for blood pressure treatment, as recommended by the American Diabetes Association standards of medical care in diabetes 2018 1.
Key Components of the Pharmacological Protocol
- Patients with confirmed office-based blood pressure ≥140/90 mm Hg should have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals, in addition to lifestyle therapy 1.
- Patients with confirmed office-based blood pressure ≥160/100 mm Hg should have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes, in addition to lifestyle therapy 1.
- Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers, thiazide-like diuretics, or dihydropyridine calcium channel blockers 1.
- Multiple-drug therapy is generally required to achieve blood pressure targets, but combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used 1.
Monitoring and Adjustments
- For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored at least annually 1.
- The pharmacological protocol should be adjusted based on patient response, with timely titration of pharmacologic therapy to achieve blood pressure goals, and consideration of alternative medications for patients with contraindications or allergies.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Pharmacological Protocol for Hypertension
The pharmacological protocol for hypertension involves various classes of medications, including:
- Diuretics
- Beta blockers
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin-II antagonists
- Calcium channel blockers
Combination Therapy
Combination therapy is often necessary to achieve adequate blood pressure control, as a single medication may not be sufficient to reach the target blood pressure of less than 140/90 mm Hg 2. The combination of an ACE inhibitor and a diuretic has been shown to be effective in reducing ambulatory blood pressures and arterial stiffness in patients with isolated systolic hypertension 3.
Specific Medication Combinations
Studies have compared the effectiveness of different medication combinations, including:
- A diuretic (bendrofluazide) vs. a beta-blocker (atenolol) in patients not controlled on amlodipine and lisinopril, with the diuretic showing a significant fall in blood pressure 4
- A fixed-dose ACE inhibitor-diuretic combination (fosinopril/hydrochlorothiazide) vs. monotherapy with a calcium channel blocker (amlodipine) or a diuretic (indapamide), with the combination showing greater reductions in systolic blood pressure 3
Guideline Recommendations
Guideline recommendations for hypertension treatment should be based on a thorough evaluation of the evidence, with consideration of the quality of evidence and the strength of recommendations 5. However, clinical reasoning is still necessary to make individualized treatment decisions, as evidence-based recommendations may not always apply to a particular patient 6.