ADA standards are released each January. Here is a succinct ACP review of guidelines in screening, diagnosis, treatment goals, lifestyle intervention, and drug approach to hypertension in the setting of diabetes mellitus. The chart depicts nicely the flow process of how to initiate and intensify the pharmacological therapy.
Annals of Internal Medicine
Screening and Diagnosis
- Blood pressure should be measured at every routine clinical visit. Patients with elevated blood pressure ≥140/90 should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.
- All hypertensive patients with diabetes should monitor their blood pressure at home.
Hypertension coexistent with diabetes is a common risk factor for complications, such as coronary artery disease, cerebrovascular disease, peripheral vascular disease, and diabetic kidney disease. Appropriate treatment of hypertension reduces risk for such complications.
White coat hypertension can be confirmed with home self-monitoring or 24-hour ambulatory monitoring.
Postural changes in blood pressure and pulse may be evidence of autonomic neuropathy and therefore require adjustment of blood pressure targets.
- Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mm Hg and a diastolic blood pressure goal of <90 mm Hg.
- Lower systolic and diastolic blood pressure targets, such as 130/80 mm Hg, may be appropriate for individuals at high risk of cardiovascular disease, if they can be achieved without undue treatment burden. (Grade C recommendation)
The ADA Standards of Medical Care emphasize individualization of blood pressure targets. Guidelines from other organizations and large randomized trials clearly establish that treating patients with baseline systolic blood pressure of 140 mm Hg or greater to targets below this level is beneficial.
More intensive targets may offer additional benefits for some patients but may also incur additional costs. Patients and clinicians should engage in a shared decision-making process to determine individual blood pressure targets.
Factors that may influence targets include risks of treatment such as hypotension or drug adverse effects; life expectancy; comorbidities, including vascular and renal complications; patient attitude and expected treatment efforts; and resources and support system. In older adults, individualized blood pressure goals should minimize other risks, such as falls.
- For patients with blood pressure >120/80 mm Hg, lifestyle intervention consists of weight loss if overweight or obese; a DASH–style dietary pattern including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity.
Lifestyle intervention should be initiated along with pharmacologic therapy when hypertension is diagnosed. In patients with blood pressure >120/80 mm Hg, lifestyle interventions include losing weight if the patient is overweight or obese; following the DASH dietary pattern, including restricting sodium intake (<2300 mg/d) and increasing intake of potassium, fruits and vegetables (8 to 10 servings per day), and low-fat dairy products (2 to 3 servings per day); avoiding excessive alcohol consumption; and increasing activity levels. Decreasing sodium intake to no more than 1500 mg/d may improve blood pressure in certain circumstances, but restriction to this level for all patients with diabetes is not recommended.
- Patients with confirmed office-based blood pressure ≥140/90 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals.
- Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, 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.
- Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACE inhibitors, ARB, thiazide-like diuretics, or dihydropyridine CCB).
- Multiple-drug therapy is generally required to achieve blood pressure targets. However, combinations of ACE inhibitors and ARB and combinations of ACE inhibitors or ARB with direct renin inhibitors should not be used.
- An ACE inhibitor or ARB, at the maximally tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥30 mg/g creatinine. If one class is not tolerated, the other should be substituted.
- 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.
- Patients with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy.