Management of Hypertension in High-Risk Patients

Rationale for Combination Therapy

Patients with uncontrolled diabetes and hypertension are classified as high-risk and should be started immediately on combination antihypertensive therapy, as recommended by the International Society of Hypertension and the American College of Cardiology 1, 2.
Multiple international guidelines, including the American College of Cardiology and the European Society of Hypertension, recommend that high-risk patients often require 2-3 antihypertensive agents to achieve blood pressure control 1, 2, 3, 4, 5, 6.
The combination of a calcium channel blocker plus an ACE inhibitor or ARB is one of the preferred two-drug combinations across all major guidelines, according to the American Heart Association 3, 4, 6.

Lisinopril 10mg represents a reasonable starting dose that can be titrated up to 40mg daily if needed, as suggested by the American College of Cardiology 7.
Guidelines suggest starting one drug then adding a second from a different class, which is exactly what is being done, according to the American College of Cardiology 3, 4, 5.

Target BP in diabetic patients should be <130/80 mmHg, and this combination significantly increases the likelihood of achieving goal, as recommended by the American College of Cardiology 1, 2, 7.

Monitor serum potassium and renal function within 1-2 weeks of adding lisinopril, especially given the diabetes and potential for underlying renal impairment, as recommended by the American College of Cardiology 5, 7.
Never combine two drugs from the same class or two drugs targeting the same system, as high-quality RCT data demonstrate that simultaneous RAS blockade increases cardiovascular and renal risk, according to the American College of Cardiology 5.

If BP remains uncontrolled on amlodipine + lisinopril, the next step is adding a thiazide or thiazide-like diuretic, preferably chlorthalidone or indapamide, as recommended by the American College of Cardiology 1, 2, 3, 4, 6.
Reassess BP control within 3 months and titrate therapy to achieve target BP <130/80 mmHg, as recommended by the American College of Cardiology 1, 2.