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Diabetes with Hypertension

This article aims to provide a simple management algorithm for the management of people with diabetes mellitus who also have raised blood pressure, making sense of the numerous (sometimes conflicting) published guidelines.

Epidemiology1
  • Hypertension is more prevalent in patients with type 2 diabetes than in the non-diabetic population.
  • It is estimated that the prevalence of arterial hypertension (blood pressure greater than 160/95 mmHg) in patients with type 2 diabetes is in the range of 40-50%.
  • Adults who have both diabetes and hypertension have more renal disease and atherogenic risk factors including dyslipidaemia, hyperuricaemia, elevated fibrinogen and left ventricular hypertrophy.
Measuring blood pressure2
  • Use properly maintained, calibrated and validated device.
  • Measure BP after sitting for 5 minutes (standing BP may have to be used if possibility of orthostatic hypotension).
  • Use cuff of appropriate size, remove tight clothing, support arm at heart level, ensure the hand is relaxed and avoid talking during procedure.
  • Record mean of at least 2 readings - more than 2 if there is >10 mmHg between the readings.
Management
Treatment threshold
  • Treat if BP =140/80 mmHg; OR if microalbuminuria or proteinuria is present, or signs of other target organ damage.2,3
  • In patients with target organ damage, lowering BP reduces the risk of CVD. Target organ damage includes:
Quality and outcomes framework indicators

The Quality and Outcomes Framework indicators for blood pressure in patients with diabetes are:

  • The percentage of patients with diabetes who have a record of the blood pressure in the previous 15 months (3 points; payment stages 40-90%)
  • The percentage of patients with diabetes in whom the last blood pressure is 145/85 or less (18 points; payment stages 40-60%)

Recommendations for pharmacological management of raised blood pressure in people with type 2 diabetes.1
 
Blood pressure
10-year coronary event risk
Microalbuminuria or proteinuria present
Recommendations
1
140/80 mmHg or higher, but less than 160/100 mmHg
Lower (no history of CVD and 10-year coronary event risk 15% or less)
No
  • Monitor blood pressure every 6 months or more frequently if necessary.
  • If 10-year coronary event risk is subsequently found to have increased to the higher risk level, treat according to (2) below.
  • If blood pressure rises to a level persistently equal to or greater than 160/100 mmHg, treat according to (3) below.
2
140/80 mmHg or higher, but less than 160/100 mmHg
Higher (history of CVD or 10-year coronary event risk over 15%)
No
  • Offer pharmacological treatment to reduce blood pressure.
  • Aim for a target blood pressure below 140/80 mmHg.
3
160/100 mmHg or higher
Higher or lower
No
  • Offer pharmacological treatment to reduce blood pressure.
  • Aim for a target blood pressure below 140/80 mmHg.
4
140/80 mmHg or higher
Higher or lower
Yes
  • Offer pharmacological treatment to achieve a target blood pressure equal to or less than 135/75 mmHg.
  • Use ACE inhibitors as the class of first choice to treat people with microalbuminuria or proteinuria.
  • Where ACE inhibitors are unsuitable or are contraindicated in people with microalbuminuria or oroteinuria, then angiotensin II receptor antagonists may be considered as alternative first-line therapy.
  • Drug classes that may be used in combination therapy with ACE inhibitors or angiotensin II receptor antagonists include beta-blockers, long acting calcium channel blockers or thiazide diuretics.

Recommendations for combining drugs3
 

Most people with diabetes

Afro-Caribbean patients

Older patients (>70) or patients with ischaemic heart disease
Step 1
ACE inhibitor (or angiotensin receptor blocker if ACE inhibitor not tolerated)
Calcium channel blocker (dihydropyridine or rate limiting) or thiazide diuretic
Thiazide diuretic
Step 2
ACE inhibitor (or angiotensin receptor blocker) plus thiazide diuretic
ACE inhibitor (or angiotensin receptor blocker) plus (calcium channel blocker or thiazide diuretic)
ACE inhibitor (or angiotensin receptor blocker) plus thiazide diuretic
Step 3
ACE inhibitor (or angiotensin receptor blocker) plus thiazide diuretic plus calcium channel blocker
Step 4
Add either:
  • Beta blocker (not with asthma or with diltiazem or verapamil)
  • Alpha blocker (not with heart failure)
  • Spironolactone (not if creatinine is above 200 mmol/L; monitor potassium)
  • Furosemide (only in chronic renal failure)

Notes

  • There is little to chose between drugs within each class; in general use the most cost-effective drug available at the time.
  • This is just a guide, where there are other disease processes going on it may be appropriate to use fourth line drugs earlier (e.g. alpha blockers in men with benign prostatic hypertrophy, beta-blockers in patients with angina, etc).
  • Titrate dose to maximum tolerated dose at each step, e.g. 40 mg/day of lisinopril.
  • Start aspirin (unless contraindicated) once BP is coming under control (<150/90).
Document references
  1. NICE Clinical Guideline; Type 2 diabetes - Blood pressure management. October 2002.
  2. Williams B, Poulter NR, Brown MJ, et al; British Hypertension Society guidelines for hypertension management 2004 (BHS-IV): summary. BMJ. 2004 Mar 13;328(7440):634-40.
  3. No authors listed, JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice. Heart. 2005 Dec;91 Suppl 5:v1-52.
Acknowledgements EMIS is grateful to Dr Colin Tidy for writing this article and to Dr Huw Thomas for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 2050
Document Version: 20
DocRef: bgp25270
Last Updated: 25 Mar 2008
Review Date: 25 Mar 2010




















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