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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.
- 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.
- 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.
- Lifestyle advice: dietary advice, reduce salt intake (<6g/day), increase aerobic exercise.
- Reduce other risks of cardiovascular disease and other complications of diabetes, e.g. smoking cessation, weight reduction, improve glycaemic control, management of diabetic nephropathy (including microalbuminuria), management of hyperlipidaemia.
- Rigorous control of blood pressure: to reduce the systolic BP <130 and diastolic <80 mmHg.2 Where there is diabetic nephropathy (microalbuminuria, proteinuria or chronic renal failure) the target should be <125/75.
- 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:
- Established ischaemic heart disease
- Cerebrovascular disease (stroke or transient ischaemic attack)
- Diabetic nephropathy (microalbuminuria, proteinuria or chronic renal failure)
- Diabetic or hypertensive retinopathy
- Left ventricular hypertrophy (ECG or echocardiogram)
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 |
|
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 |
|
3 |
160/100 mmHg or higher |
Higher or lower |
No |
|
4 |
140/80 mmHg or higher |
Higher or lower |
Yes |
|
|
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:
|
||
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
- NICE Clinical Guideline; Type 2 diabetes - Blood pressure management. October 2002.
- 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.
- 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.
DocID: 2050
Document Version: 20
DocRef: bgp25270
Last Updated: 25 Mar 2008
Review Date: 25 Mar 2010
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