Management of Hypertension in Type 2 Diabetes

Introduction to Blood Pressure Management

The American College of Cardiology and other guideline societies recommend that blood pressure control must be a priority in the management of patients with hypertension and type 2 diabetes, with a target blood pressure of <130/80 mmHg for most patients to reduce cardiovascular and renal complications 1, 2

Target blood pressure should be <130/80 mmHg for most patients with type 2 diabetes to reduce cardiovascular morbidity and mortality 1, 2
For elderly patients (>65 years) and those with severe coronary heart disease, a less stringent target of <140/90 mmHg may be appropriate 2
Diastolic blood pressure should be maintained around 80 mmHg, as a 4-point reduction from 85 to 81 mmHg resulted in a 50% decrease in cardiovascular events in diabetic patients in the HOT study 3

The American Diabetes Association and other guideline societies recommend that ACE inhibitors or ARBs should be the first-line agents for blood pressure control in most patients with type 2 diabetes 1, 2, 4
These agents provide additional benefits beyond blood pressure control, including renoprotection and reduced cardiovascular mortality 4
ARBs are an acceptable alternative to ACE inhibitors if ACE inhibitors are not tolerated 4

For African American patients, thiazide diuretics should be considered as first-line therapy due to greater efficacy in this population 3, 4
For patients with diabetic nephropathy, ACE inhibitors or ARBs are strongly preferred for their renoprotective effects 4

Multiple-drug therapy is often required to achieve blood pressure targets in patients with type 2 diabetes 1, 6
If blood pressure remains uncontrolled on initial therapy, add a calcium channel blocker or thiazide-like diuretic 1, 2

Lifestyle modifications should be implemented alongside pharmacological therapy 1, 7
Weight reduction is an effective measure in the management of hypertension in diabetic patients 7
Moderate sodium restriction (to approximately 2,300 mg/day) can reduce systolic blood pressure by about 5 mmHg 7
Regular physical activity (30-45 minutes of brisk walking most days) helps lower blood pressure 7
Adopting a DASH or Mediterranean-style eating pattern with increased consumption of fruits, vegetables, and low-fat dairy products 1

Monitor blood pressure regularly to ensure target achievement 1
Check renal function and serum potassium within 3 months of starting ACE inhibitors, ARBs, or diuretics 6
Encourage home blood pressure self-monitoring 6
Assess adherence to medications and lifestyle modifications at each visit 1

Recognize that most patients will require 2-3 antihypertensive medications to achieve target blood pressure 4