250 A.D.-Apollinius of Memphis coins the name ‘diabetes’
1674-Thomas Willis publishes ‘The Diabetes or Pissing Evil’. Writes ‘those laboring with this Disease, piss a great deal more than they drink’ asserting that all diabetic urine ‘was wonderfully sweet as if it were imbued with Honey or Sugar’
1910- English physiologist, Sir Edward Albert Sharpey-Schafer, suggested that a single chemical component was missing from the pancreas of diabetics and called it “insulin”.
1922- Banting and Best (a medical student) isolate insulin (‘ilsetin’ or ‘iletin’) and inject the ‘thick brown muck’ into a 14 year old boy (7.5 ml into each buttock) producing some fall in glucose complicated by abscesses
* FBG blood test is done after fasting 8 hours. ** GTT results are repeated after 2 hours. A person drinks a 75 mg glucose solution before test. 100 mg for Pregnant women. Normal Pre diabetes Diabetes Fasting Blood Glucose Test (FBG)* Less than 100 Between 100 - 125 More than or equal to 126 Glucose Tolerance Test (GTT) ** Less than 140 Equal to or more than 140 but less than 200 More than or equal to 200
But treatment of hypertension in diabetes mellitus is not always easy and much confusion prevail regarding ------
Target blood pressure
Use of specific agents like ACE inhibitors, ARB, thiazide diuretics and beta-blockers and their adverse effects.
Definition, screening and diagnosis According to Joint National Committee – 7 (JNC-7) Staging SBP DBP Normal <120 <80 Prehypertensive 120-139 80-89 Stage 1 hypertension 140-159 90-99 Stage 2 hypertension >160 >100
In Prehypertensive------- Life style modification Stage 1 & 2 Should be treated But Prehypertensive + diabetes mellitus /CKD Life style modification,if it fails to redude BP to <130/80 mm Hg then--- Start drug therapy
Excessive salt sensitivity and increased extracellular volume:
BP of diabetic patients is more sensitive to salt intake and this sodium sensitivity is found even in absence of nephropathy.
A decreased salt intake is important for diabetic patients with hypertension.
Diabetes ,hypertension and nephropathy--- Increased systolic BP is a significant risk factor for micro albuminuria and rapid progression of nephropathy. Isolated systolic hypertension----- ISH is strongly related to development of micro and macrovascular diseases in patients with DM.
American Diabetes Association recommends target blood pressure levels of <130/80 mm Hg.
In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110-129/65-79mm Hg are suggested in the interest of long term maternal health and minimizing impaired fetal growth.
Non-pharmacological management of hypertension in diabetes
Weight loss Loss of weight by 1kg decreases BP by approx 1mm hg. Sodium restriction Decrease in sodium intake from 4.6 gm to 2.3 gm/day results in reduction of 5mm Hg is SBP and 2-3 mm Hg in DBP. Exercise Diabetic patients who are 35 yrs of age or older and are planning to begin a vigorous exercise programme should have exercise stress testing or other appropriate non-invasive testing. At least 150 min of moderate intensity aerobic physical activity is recommended per week. Smoking cessation Moderation of alcohol intake.
It has been recommended that all patients should receive either an ACE inhibitor or ARB.
Multiple drug therapy is generally required to achieve target blood pressure.
Aspirin therapy is recommended in patients of diabetes with hypertension.
(ADA position statement diabetes care 30:54- 541, 2007)
Statin therapy should be given to achieve LDL cholesterol level <100 mg/dl.
Pharmacological therapy Thiazide diuretic and Beta Blockers - There have been concerns among physicians as many studies have shown thiazides and beta blockers promote glucose intolerance. Inspite of this both agents have been recommended for treatment of hypertension in DM, lower doses of shorter acting thiazides- hydrochlorthiazide instead of chlorethalidone are generally well tolerated and not associated with adverse metabolic effects. Recommendations for beta blockers are-- combined alpha and beta blocker should be preferable agents. Carvedilol is the potential agent of choice as it effectively control blood pressure and improves insulin sensitivity and decreases HbA1C.
Reduce cardiovascular mortality and progression of renal disease.
Increases upto 30-35% from baseline serum creatinine level (creatinine of 3mg/dl or less) that stablize with in the first 2 months of ACE inhibitors therapy should not deter use of these agents.(Arch Intern Med 2000).
combination of ACE inhibitors and ARBs causes dual blockade of RAS and provides superior renoprotection but serum potassium level should be monitored causitiously.
The UKPDS and systolic hypertension in Europe trial (Syst-Eur) have shown beneficial effects for both ACE inhibitors and calcium channel blockers in patients with diabetes.
Modulation of the renin angiotensin system has particular importance in diabetic patients.
ACE inhibitors reduces nephropathy and end stage renal disease in patients with type 1 diabetes, and angiotensin receptor blockers reduce the risk of these microvascular disorders in patient with type 2 diabetes.
In the Heart Outcomes and Prevention Evaluation (HOPE) study, ramipril significantly decreased the rates of myocardial infarction ,stroke and death in patients with diabetes and a mean blood pressure of 140/80 mm Hg.
The Losartan Intervention For End point (LIFE) study enrolled 1195 diabetic subjects as part of the cohort. Participants had hypertension and evidence of left ventricular hypertrophy, subjects were randomized to losartan or atenolol. Despite equivalent blood pressure lowering, the subjects randomized to losartan experienced a 39 percent reduction in all cause mortality, a 37 percent reduction in cardiovascular mortality, and a 21 percent reduction in stroke.
Treatment Program for Patients with Hypertension and Diabetes
How Can You Help Reduce Your Risk of Hypertension in Diabetes ? Eat foods low in fat & calories. If overweight, lose weight. Physical activity Stop smoking! Limit alcohol to 1-2 drinks per day. Take your medications regularly.
What are goals to healthy living? Be SMART S pecific M easurable A chievable R elevant T ime