Management of Hypertension, Type 2 Diabetes, and Hypothyroidism

Blood Pressure Management

The American Diabetes Association recommends targeting blood pressure <130/80 mmHg for most patients with diabetes and hypertension 1, 2
A less stringent target of <140/90 mmHg may apply in elderly patients and those with severe coronary heart disease 1, 2
Blood pressure should be measured at every routine diabetes visit 3, 4
For BP ≥140/90 mmHg: Initiate pharmacologic therapy immediately along with lifestyle modifications 3, 4
ACE inhibitors or ARBs are the preferred first-line agents for diabetic patients with hypertension 1, 3, 2, 4
Multiple-drug therapy is generally required to achieve blood pressure targets in diabetic patients 3, 4, 6
Monitor serum creatinine/eGFR and potassium at least annually when using ACE inhibitors, ARBs, or diuretics 3
Resistant hypertension is defined as BP ≥140/90 mmHg despite appropriate lifestyle management plus a diuretic and two other antihypertensive drugs at adequate doses 3
Mineralocorticoid receptor antagonists are effective when added to existing ACE inhibitor/ARB, thiazide-like diuretic, and dihydropyridine calcium channel blocker 3

The American Diabetes Association recommends that all diabetic patients over age 40 with hypertension should be on statin therapy regardless of baseline lipid levels 3, 7
Start with moderate-intensity statin and adjust based on response and tolerability 1, 2
Primary goal: LDL-C <100 mg/dL (2.6 mmol/L) for patients without overt CVD 1, 2, 7
For very high-risk patients or those with overt CVD: LDL-C <70 mg/dL (1.8 mmol/L) using high-dose statin 7
Obtain fasting lipid profile at least annually 3, 7, 4

Reduce sodium intake to 1200-2300 mg/day 4
Reduce saturated fat, trans fat, and cholesterol intake 7, 4
Increase consumption of fresh fruits, vegetables, and low-fat dairy products 4
Increase dietary fiber and omega-3 fatty acids 7, 4
At least 150 minutes of moderate-intensity aerobic activity per week, distributed over at least 3 days with no more than 2 consecutive days without activity 4

Never combine ACE inhibitors with ARBs 3
Never combine ACE inhibitors or ARBs with direct renin inhibitors 3
Failure to monitor renal function and potassium when using renin-angiotensin system blockers can lead to dangerous hyperkalemia 3, 4
Inadequate monitoring of thyroid function during levothyroxine therapy can result in persistent hypothyroidism or iatrogenic hyperthyroidism 3
Most patients require multiple drugs to achieve blood pressure targets 3, 4, 6
Delaying intensification of therapy when targets are not met contributes to poor outcomes 7