Hypertension Management in Diabetes

Introduction to Hypertension Management

The American Diabetes Association recommends ACE inhibitors or ARBs as the first-line treatment for hypertension in patients with diabetes, particularly for those with albuminuria or coronary artery disease, with addition of thiazide-like diuretics and/or dihydropyridine calcium channel blockers when blood pressure targets are not met 1
Prompt pharmacologic therapy should be initiated when blood pressure is ≥140/90 mmHg in patients with diabetes 1

Target blood pressure for patients with diabetes is <130/80 mmHg, although the exact target may vary depending on individual patient characteristics 1
For blood pressure between 140/90 mmHg and 159/99 mmHg, treatment should start with a single drug 1
For blood pressure ≥160/100 mmHg, immediate initiation of two antihypertensive medications is recommended 1
The combination of an ACE inhibitor or ARB with a thiazide-like diuretic and/or a dihydropyridine calcium channel blocker may be used to achieve blood pressure targets 1

For patients with albuminuria (UACR ≥30 mg/g creatinine) or coronary artery disease, an ACE inhibitor or ARB at maximum tolerated dose is recommended, with a strong recommendation for UACR ≥300 mg/g creatinine (A level evidence) and a recommendation for UACR 30-299 mg/g creatinine (B level evidence) 1
For patients without albuminuria, any of the following drug classes that have demonstrated cardiovascular event reduction may be used: ACE inhibitors or ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers 2
Chlorthalidone or indapamide are the preferred thiazide-like diuretics due to their longer duration of action and stronger evidence for cardiovascular event reduction, as recommended by the American Diabetes Association 2, 3
Hydrochlorothiazide is an alternative option if the preferred agents are unavailable 2

Do not combine ACE inhibitors with ARBs, as this increases the risk of adverse effects without additional benefit 2
Do not combine ACE inhibitors or ARBs with direct renin inhibitors, as this also increases the risk of adverse effects without additional benefit 2
Combining ACE inhibitors with ARBs should be avoided, as it increases the risk of adverse effects without additional benefit 3, 1, 4

Check serum creatinine, eGFR, and potassium levels within 2-4 weeks of initiating therapy and at least annually thereafter 1
Titrate to maximum tolerated dose indicated for blood pressure treatment, as higher doses of ACE inhibitors or ARBs are more effective for reducing proteinuria 1
Annual quantitative assessment of urinary albumin (UACR) and estimated GFR is recommended in all patients with type 2 diabetes and in type 1 diabetes with ≥5 years duration 5
Monitor for potential adverse effects, including electrolyte disturbances, metabolic effects, and volume depletion symptoms 4, 2

Implement lifestyle modifications alongside pharmacological therapy, including weight loss if overweight or obese, DASH dietary pattern, sodium restriction (<2,300 mg/day), physical activity (at least 150 minutes/week), and moderation of alcohol consumption 2
A diet high in fruits, vegetables, whole grains, and nuts is recommended to reduce cardiovascular risk 6, 7
Reduction of protein intake to 0.8–1.0 g/kg body weight/day is recommended in individuals with diabetes and earlier stages of CKD, and 0.8 g/kg body weight/day for later stages of CKD 7, 6

Hypertension management in diabetes should be part of a comprehensive cardiovascular risk management strategy that includes lipid control (statin therapy), diabetes management, smoking cessation, and limited sodium intake 2
Statin therapy is recommended for all diabetic patients with cardiovascular risk factors 8
Aspirin therapy is recommended for secondary prevention in patients with diabetes and history of ASCVD 9
Smoking cessation is recommended for all patients with diabetes 10
Establish an interdisciplinary team approach for comprehensive diabetes management, including consideration of referral to specialists such as nephrology, cardiology, neurology, podiatry, and ophthalmology when appropriate 7, 6, 5

If blood pressure remains uncontrolled despite optimized doses of all three agents (ARB, CCB, and thiazide-like diuretic), the next step would be to add a mineralocorticoid receptor antagonist (spironolactone), as supported by evidence from the American Diabetes Association 4, 2, 3, 1, 8, 11
Resistant hypertension may require the addition of a mineralocorticoid receptor antagonist (spironolactone) when BP remains uncontrolled on three medications, including a diuretic 1, 8
Consider medication adherence testing if blood pressure remains uncontrolled despite multiple medications, as recommended by the American Heart Association 12