Treatment of Hypertension

Canadian Diabetes Association Clinical Practice Guidelines Expert Committee

Richard E. Gilbert MBBS, PhD, FRCPC Doreen Rabi MD, FRCPC, MSc Pierre LaRochelle MD, PhD, FRCPC Lawrence A. Leiter MD, FRCPC, FACP, FAHA Charlotte Jones PhD, MD Richard Ogilvie MD, FRCPC, FACP Sheldon Tobe MD, FRCPC Nadia Khan MD, FRCPC, MSc Luc Poirier BPharm MSc Vincent Woo MD, FRCPC

  • Key Messages
  • Recommendations
  • Figures
  • Highlights
  • Full Text
  • References

Key Messages

  • People with diabetes should be treated to achieve a blood pressure (BP) <130/80 mm Hg.

Highlights of Revisions

  • The revisions of these recommendations were completed through collaboration with the Canadian Hypertension Education Program (CHEP).
  • It is recommended that people with diabetes be treated to achieve and maintain a blood pressure (BP) <130/80 mm Hg.
  • Recommendations regarding combination therapy have been expanded since 2008.
  • Strong recommendation added for the use of angiotensin-converting enzyme (ACE) inhibitor or angiotensin II receptor blocker (ARB) therapy as first-line in patients with cardiovascular disease, kidney disease (including microalbuminuria) or any cardiovascular risk factors.
  • Recommendation to use dihydropyridine calcium channel blocker (CCB) as the add-on therapy to ACE inhibitor instead of hydrochlorothiazide.

Recommendations

  1. 1.Persons with diabetes mellitus should be treated to attain SBP <130 mm Hg [Grade C, Level 3 (1,2)] and DBP <80 mm Hg [Grade B, Level 1 (3)]. (These target BP levels are the same as the BP treatment thresholds). Combination therapy using 2 first-line agents may also be considered as initial treatment of hypertension [Grade C, Level 3 (4,5)] if SBP is 20 mm Hg above target or if DBP is 10 mm Hg above target. However, caution should be exercised in patients in whom a substantial fall in BP is more likely or poorly tolerated (e.g. elderly patients, patients with autonomic neuropathy).
  2. 2.For persons with cardiovascular or kidney disease, including microalbuminuria, or with cardiovascular risk factors in addition to diabetes and hypertension, an ACE inhibitor or an ARB is recommended as initial therapy [Grade A, Level 1A (6–9)].
  3. 3.For persons with diabetes and hypertension not included in the above recommendation, appropriate choices include (in alphabetical order): ACE inhibitors [Grade A, Level 1A (10)], ARBs [Grade A, Level 1A (7)], dihydropyridine CCBs [Grade A, Level 1A (10)], and thiazide/thiazide-like diuretics [Grade A, Level 1A (10)].
  4. 4.If target BP levels are not achieved with standard dose monotherapy, additional antihypertensive therapy should be used [Grade D, Consensus]. For persons in whom combination therapy with an ACE inhibitor is being considered, a dihydropyridine CCB is preferable to hydrochlorothiazide [Grade A, Level 1A (11)].

Abbreviations:
ACE, angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP, blood pressure; CCB, calcium channel blocker; DBP, diastolic blood pressure; SBP, systolic blood pressure.

References

  1. Adler AI, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;321:412-9.
  2. Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002;61:1086-97.
  3. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. Lancet 1998; 351:1755-62.
  4. UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703-13.
  5. Cushman WC, Ford CE, Cutler JA, et al. Success and predictors of blood pressure control in diverse North American settings: the Antihypertensive and Lipid- Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens 2002;4:393-404.
  6. Lewis EJ, Hunsicker LG, Clarke WR, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Eng J Med 2001;345:851-60.
  7. Lindholm L, Ibsen J, Dahlof B, et al. Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002; 359:1004-10.
  8. The Heart Outcomes Prevention Evaluation Study Investigators. Effects of an angiotensin-converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000;342:145-53.
  9. Brenner BM, Cooper ME, de Zeeuw D, et al. The losartan renal protection study: rationale, study design and baseline characteristics of RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan). J Renin Angiotensin Aldosterone Syst 2000;1:328-35
  10. Whelton PK, Barzilay J, Cushman WC, et al. Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2005;165:1401-9.
  11. Weber MA, Bakris GL, Jamerson K, et al. Cardiovascular events during differing hypertension therapies in patients with diabetes. J Am Coll Cardiol 2010;56: 77-85.

 

Reproduced with permission from Canadian Journal of Diabetes © 2013 Canadian Diabetes Association. To cite this article, please refer to For citation.

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