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%)

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).