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presented in endocrinology conference, Jeddah October 2009.

presented in endocrinology conference, Jeddah October 2009.

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Management Of Hypertension in diabetes- 2009 Management Of Hypertension in diabetes- 2009 Presentation Transcript

  • Management of
    Hypertension
    in Diabetes-2009
    Dr Mohamed Al-Ameen
    Nephrologist & Transplant Physician
    KAAH&OC- Jeddah
  • بسم الله الرحمن الرحيم
  • 1.5 billions
  • Over 1.5 billion people worldwide
    are hypertensive
    Or 1 in 3 adult
  • > 7 Millions
  • Hypertension
    7 million deaths/ year
  • 171,000,000
    Prevalence of DM worldwide “2000”
    366,000,000
    Prevalence of DM worldwide “2030”
    Prevalence of DM KSA “2000”
    890,000
    Prevalence of DM KSA “2030”
    2,523,000
    e DM + HTN KSA “2000”
    543,000
    e DM + HTN KSA “2030”
    1,513,800
  • Dark Numbers
    171,000,000
    Prevalence of DM worldwide “2000”
    366,000,000
    Prevalence of DM worldwide “2030”
    Prevalence of DM KSA “2000”
    890,000
    Prevalence of DM KSA “2030”
    2,523,000
    e DM + HTN KSA “2000”
    543,000
    e DM + HTN KSA “2030”
    1,513,800
  • The Third National Health and Nutrition Evaluation Survey (NHANES III)
    • About HTN in Diabetic Pts:
    • 29% unaware about that diagnosis.
    • 43% untreated.
    • 65% uncontrolled (≥140/90).
    • Only 12% had BP <130/85.
    Am J Prev Med 22:42–48, 2002 Hypertension 52:818-827, 2008
  • Management of Hypertension in Diabetics
    Hypertension in Diabetes
    Prevalence
    NEJM 2000; 342:905 DiabetesCare 2005; 28:310 AmJKidDis 2007; 49 (Suppl 2):S74
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    Diabetes
    Hypertension
    HTN vs No HTN DM vs No DM
    2.4x ↑ in DM 2.0x ↑ in HTN
    NEJM 2000; 342:905 Diabetes Care 2005; 28:310
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    NEJM 2005; 352:341
    AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 7 / OCTOBER 1, 2002
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    “Refractory HTN”
    The HIPERFRE study, 2008
    The HIPERFRE study, 2008
    1,724 hypertensive patients, 35 physicians, 14 Primary Care Units
    1,724 hypertensive patients, 35 physicians, 14 Primary Care Units
    Association between refractory hypertension and cardiometabolic risk
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    Diabetes
    Hypertension
    Cause: Mainly renoparenchymal and pointing to DN
    Onset: Typically with microalbuminuria
    American diabetic association, Diab Care 2004
    DM-1
    Cause: Mainly Insulin Resistance as a facet of MS.
    Onset: with onset of Diabetes or may precede that by Ys.
    Ritz et al. J Int Med.2001;249: 215-223.
    DM-2
  • Kidney
    Disease
    DM-1
    Metabolic Syndrome
    HTN
    DM-2
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    So,
    The pathogenesis of development is distinct in each type
    BUT
    The pathogenesis of marked enhancement of the already high risk of cardiovascular and renal disease in types 1 and 2 are similar in both
    Landsberg L, Molitch M. Clin Exp Hypertens 2004 Oct-Nov;26(7-8):621-8.
  • Management of Hypertension in Diabetics
    Diabetes
    Hypertension
    Studies
    1- Pollare T et al. Metabolism 1990, 39(2):167-174 :
    There are resistance to insulin and hyperinsulinemia: in hypertensive pts non diabetic compared with normotensive controls.
    2- Bosch J et al. N Engl J Med 2006, 355(15):1551-1562:
    About 20% of patients with hypertension will develop type 2 diabetes in a three year period
    3- BarzilayJ I et al. Arch Intern Med. 2006;166:2191-2201:
    Fasting glucose levels increase in older adults with hypertension
    regardless of treatment type.
  • Management of Hypertension in Diabetics
    Diabetes
    Hypertension
    Studies
    4- Jandeleit-Dahm KA et al. J Hypertens 2005, 23(3):463-473 :
    - The RAS itself plays imp. role in the development of diabetes.
    - Over activity of RAS appears to be linked to reduced insulin and glucose delivery to the peripheral skeletal muscle and impaired glucose transport and response to insulin signalling pathways, thus increasing insulin resistance.
    5- Ferrannini E et al. Diabetologia 2003, 46(9):1211-1219:
    Activation of a local pancreatic RAS, in particular within the islets, may represent an independent mechanism for the progression of islet cell damage in diabetes.
  • Diabetes
    Hypertension
    Drugs
    Elliott WJ, Meyer PM: anetwork meta-analysis. Lancet 2007, 369(9557):201-207.
  • Diabetes
    Hypertension
    Drugs
    Gupta AK et al.  Diabetes Care. 2008 May;31(5):982-8.
  • Management of Hypertension in Diabetics
    Diabetes
    Hypertension
    Drugs
    Role of Antihypertensive Drugs
    11.6%
    • The risk of diabetes associated
    with antihypertensive-drug therapy
    appears to be explained by the
    presence of hypertension.
    • Among the subjects who had
    hypertension, the risk among those
    not taking medication was similar to
    that among those taking one or
    more agents.
    • Among the subjects who were not
    taking any antihypertensive
    medication, the risk of diabetes
    was much higher among
    hypertensive Pts. than in non
    hypertensive.
    9.8%
    8.1%
    Chlorthalidone
    Amlodipine
    Lisinopril
    ALLHAT: Incidence of New-Onset Diabetes at 4 Years
    JAMA 2002;288:2981-2997
    Gress TW et al. N Engl J Med. 2000 Mar 30;342(13):905-12.
  • Management of Hypertension in Diabetics
    Diabetes
    Hypertension
    Drugs
    Role of Antihypertensive Drugs
    • DM was 28 percent more likely
    to develop in subjects taking
    BB than in those taking no
    medication.
    • This adverse effect of BB must
    be weighed against the proven
    benefits of this drug in reducing
    the risk of cardiovascular events
  • This adverse effect of BB must
    be weighed against the proven
    benefits of this drug in reducing
    the risk of cardiovascular events
  • Diabetes
    Hypertension
    Risk
    Verdecchia P et al. Hypertension. 2004;43:963-969.
  • Diabetes
    Hypertension
    Predictors
  • Diabetes
    Hypertension
    Prevention
    Screen for NOD in hypertensive Pts. As they share common etiological factors.
    Use of drugs that inhibit RAS.
    LIFE, ALLHAT and CAPP.
    Fixed dose combination ACE-I + CCB (Trandolapril + Verapamil): lower risk of NOD
    Cheung BM. Diabetes Care. 2008 Sep;31(9):1889-91.
    Bakris G et al. Diabetes Obes Metab. 2008 Jun 16
  • Any 3 of the following 5 features
    Central obesity
    􀂄 apple vs pear shape
    Elevated TG
    Low HDL-cholesterol
    Elevated blood pressure
    Elevated fasting plasma glucose or previously undiagnosed type 2 diabetes
    Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
  • Any 3 of the following 5 features
    Central obesity
    􀂄 apple vs pear shape
    Elevated TG
    Low HDL-cholesterol
    Elevated blood pressure
    Elevated fasting plasma glucose or previously undiagnosed type 2 diabetes
    Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    Criteria of MS
    Central obesity: Waist circumference
    􀂄 &gt; 40 inches (men)
    􀂄 &gt; 35 inches (women)
    Elevated Triglycerides
    􀂄 &gt; 150 mg/dl or on TG therapy
    Low HDL-cholesterol
    􀂄 &lt; 40 (men)
    􀂄 &lt; 50 (women)
    􀂄 Or on therapy to increase HDL-cholesterol
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    Criteria of MS
    Elevated blood pressure
    &gt; 130/85 mmHg or on bp therapy
    Elevated fasting plasma glucose
    Fasting glucose &gt; 100 mg/dl or
    Previously undiagnosed type 2 diabetes
    Fasting glucose &gt; 126 mg/dl on 2 separate occasions
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
    Risk of MS
    Heart Disease
    Type 2 Diabetes
    Polycystic Ovarian Syndrome
    Kidney Disease
    2.5 fold increase of microalbuminuria
    3.5 fold increase of chronic kidney disease
    Cancer
    Nonalcoholic steatohepatitis
    Alzheimer’s
  • Management of Hypertension in Diabetics
    HTN in DM:PARTNERS IN CRIME
  • Effect of Tight
    Control of
    Blood Pressure
  • Management of Hypertension in Diabetics
    HTN in DM:Effect of BP Control
    Tight BP Control vs. Tight Glucose Control
    Microvascular
    Any DM
    Stroke
    DM Death
    Complications
    End Point
    0 -
    -10 -
    -20 -
    Reduction in Risk (%)
    -30 -
    Tight Glucose Control
    -40 -
    Tight BP Control
    *P &lt; 0.05
    -50 -
    UKPDS. BMJ. 1998:317;703-712.
  • Management of Hypertension in Diabetics
    HTN in DM:Effect of BP Control
    Tight BP Control vs. Tight Glucose Control
    Whelton, P. K. et al. JAMA 2002;288:1882-1888
  • Management of Hypertension in Diabetics
    HTN in DM:Effect of BP Control
    Tight BP Control vs. Tight Glucose Control
    Tight BP Control
    Tight Glucose Control
  • Management of Hypertension
    In Diabetes
  • 636 pts. 24 months
    4 groups:
    Usual care.
    Behavioral intervention (bimonthly tailored nurse-administered telephone intervention targeting hypertension-related behaviors.
    Home BP monitoring.
    Combined behavioral intervention plus home BP monitoring.
    • HOME BP MONITORING
    • WEB TRAINING
    • PHARMACIST CARE INTERVENTION
  • Educational interventions directed to the patient.
    Educational interventions directed to the health. professional.
    Health professional (nurse or pharmacist) led care.
    Appointment reminder systems.
  • Home BP Monitoring
    Behavioral intervention
    Web Training
    Pharmacist Care
    Appointment reminder systems
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • HTN in DM: 1- Measure BP Properly
    The measurement of BP is likely the clinical procedure of greatest importance that is performed in the sloppiest manner.”
    (Norman Kaplan, M.D.)
    Lancet 2007; 370:591
    Health care professionals should take particular care to ensure that they are using accurate techniques to measure BP in all their patients.”
    (International Working Group, 2008)
    JHumHypertens 2008; 22:63
    CanJCard 2007; 23:529
  • HTN in DM: 1- Measure BP Properly
    Joint National Commitee
    Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. JNC-7
  • HTN in DM: 1- Measure BP Properly
    Joint National Commitee
  • Mercury Sphygmomanometers
    What is about automated devices ????????
  • We recommend that this device not be used when accurate BP measurement is needed for therapeutic decision-making.
  • HTN in DM: 1- Measure BP Properly
  • Ambulatory BP monitoring:
    White Coat HTN with TOD.
    Episodic HTN
    Autonomic dysfunction
    Drug resistance
    Self Measurement (Out of Office BP): if consistently &lt;130/80 and No TOD despite high office BP  24h monitoring & drug therapy can be avoided.
    HTN in DM: 1- Measure BP Properly
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • Management of Hypertension in Diabetics
    HTN in DM: 2- Define Hypertensive Patients
    Joint National Committee 7 (JNC-7)
  • High Normal BP and CVD Risk
  • Management of Hypertension in Diabetics
    HTN in DM:2- Define Hypertensive Patients
    Systolic or Diastolic Hypertension???????
    250
    Nondiabetic
    Diabetic
    200
    CVmortalityrate/10,000 person-yr
    150
    100
    50
    0
    &lt;120
    120-139
    140-159
    160-179
    180-199
    ≥200
    Systolic BP (mm Hg)
    CV, cardiovascular; SBP, systolic blood pressure.
    Stamler J et al. Diabetes Care. 1993;16:434-444.
    CV Mortality Risk Doubles WithEach 20/10 mm Hg BP Increment*
  • Systolic BP is stronger predictor of risk than diastolic BP:
    • Cardiovascular disease
    • Diabetic Nephropathy
    65% of DM hypertensives have isolated systolic hypertension.
    Lancet 2002; 360:1903 Hypertension 2003; 42:1206
    National Kidney Foundation: Guideline 8. Am J Kidney Dis 43 (Suppl. 1):S142 –S159, 2004.
    Sowers JR et al. Hypertension 37:1053 –1059, 2001.
  • Systolic BP should be the primary target of
    antihypertensive therapy
  • Systolic BP represent an important risk factor for CV events which can be prevented or reduced by pharmacological treatment
  • Management of Hypertension in Diabetics
    HTN in DM:2- Define Hypertensive Patients
    Systolic or Diastolic Hypertension???????
    DBP is a more potent cardiovascular risk factor than SBP until age 50; thereafter, SBP is more important.
    Diastolic hypertension predominates before age 50, either alone or in combination with SBP elevation.
    Systolic BP increases with age, and above 50 years of age, systolic hypertension represents the most common form of hypertension.
    SBP control rates are lower than that of DBP.
    J ClinHypertens 2002;4:393-404.
    Hypertension 2001;37:12-8.
    • Three-fourths of 1ry care physicians failed to initiate therapy if SBP 140-159.
    • Most physicians have been taught that the diastolic pressure is more important than SBP and thus treat accordingly.
    • Most primary care physicians did not pursue control to <140 mmHg.
    J ClinHypertens. 2000;2:324-30.
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • Evaluate for:
    CV Risk Factors.
    Target Organ Damage.
    Secondary Causes of HTN.
    Routine Laboratory work up: eg.. ECG, lipid profile and urinary albumin.
    Management of Hypertension in Diabetics
    HTN in DM:3- Evaluate Hypertensive Pts.
  • HTN
    DM*
    Age:
    Older than 55 years for men
    Older than 65 years for women
    Abnormal Lipid Profile*:
    Elevated LDL (or total) cholesterol
    Low HDL cholesterol*
    Estimated GFR &lt;60 mL/min
    Family history of premature CVD:
    men &lt;55 years of age
    women &lt;65 years of age
    Microalbuminuria
    Obesity* (BMI &gt;30 kg/m2)
    Physical inactivity
    Tobacco usage, particularly cigarettes
    Management of Hypertension in Diabetics
    HTN in DM:3- Evaluate Hypertensive Pts.
    Cardiovascular Risk Factors
    (140-age) x weight x 1.23 x (0.85 if female)
    S Creatinine (micromol/l)
    (140-age) x Weight (Kg) x (0.85 if female)
    72 x S Creatinine (mg/dl)
    Normoalbuminuria &lt; 30 mg/day
    Microalbuminuria 30 - 300 mg /d
    Macroalbuminuria &gt; 300 mg / day
    BMI= Weight (Kg) / (Height in meter)2
  • Heart
    LVH
    Angina/prior MI
    Prior coronary revascularization
    Heart failure
    Brain
    Stroke or transient ischemic attack
    Dementia
    Kidney: CKD
    Eye: Retinopathy
    Vessels: Peripheral arterial disease
    Management of Hypertension in Diabetics
    HTN in DM:3- Evaluate Hypertensive Pts.
    Target Organ Damage
  • Management of Hypertension in Diabetics
    HTN in DM:3- Evaluate Hypertensive Pts.
    2ry Causes of HTN
    ABCD diagnosis of 2ry HTN
    A: Accuracy, Apnea, Aldosteronism
    B: Bruit, Bad Kidney
    C:Catecholamines, Coarctation, Cushing&apos;s S.
    D: Drugs, Diet
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • HTN in DM:Practical Strategy
    Measure: Measure BP properly.
    Define: Define Hypertensive Patients.
    Evaluate: Evaluate hypertensive pts.
    Treat: Therapy
  • Goal Blood Pressure
    Life Style Modification
    Drug Therapy
  • Goal Blood Pressure
    Life Style Modification
    Drug Therapy
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Goal Blood Pressure
    Less Than 130/80
    HOT (Hypertension Optimal Treatment).
    ABCD-NT (Appropriate Blood Pressure Control in Diabetes)
    UKPDS (UK Prospective Diabetes Study)
    IDNT (Irbesartan in Diabetic Nephropathy Trial)
    INVEST (International Verapamil-Trandolapril)
    ADA (American Diabetic association)
    ISHIB (International Society of Hypertension in Blacks)
    CHEP (Canadian Hypertension Education Program)
    BHS (British Hypertension Society)
    JNC 7 (Joint National Committee 7)
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Goal Blood Pressure
    Less Than 130/80
    Can We Go to More Lower Target ?
    National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000;36(3):646-661.
    American Association of Clinical Endocrinologist, 2006
    Target BP 125/75 If Proteinuria &gt; 1gm
    IDNT
    JASN 2005;16(7):2170–2179
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Goal Blood Pressure
    Less Than 130/80
    Can We Go to More Lower Target ?
    20,358 individuals studied, 1549 (7.6%) had CKD
    HR of Stroke vs SBP
    Lowest Systolic Blood Pressure Is Associated with Stroke inStages 3 to 4 Chronic Kidney Disease
    J Am Soc Nephrol18: 960–966, 2007
  • Lowest Systolic Blood Pressure Is Associated with Stroke in Stages 3 to 4 Chronic Kidney Disease
    J Am Soc Nephrol18: 960–966, 2007
  • Goal Blood Pressure
    Life Style Modification
    Drug Therapy
  • Goal Blood Pressure
    Life Style Modification
    Drug Therapy
  • HTN in DM:4- Therapy
    Life Style Modifications
    Decrease Weight
    5-20 mmHg/10 kg
    Decrease Sodium
    2-8 mmHg
    4-9 mmHg
    Do Ph. Activity
    8-14 mmHg
    DASH diet
    2-4 mmHg
    Decrease Alcohol
    Smoke free enviroment
    D/C Smooking
  • Hypertensive and all patients
    BMI over 25
    - Encourage weight reduction
    • Healthy BMI: 18.5-24.9 kg/m2
    Waist Circumference Men Women
    - Europid, Sub-Saharan African, Middle Eastern &lt;94 cm &lt;80 cm
    - South Asian, Chinese &lt;90 cm &lt;80 cm
    - Japanese &lt;85 cm &lt;90 cm
    For patients prescribed pharmacological therapy: weight loss has additional antihypertensive effects. Weight loss strategies should employ a multidisciplinary approach and include dietary education, increased physical activity and behavioural modification
  • 2,300 mg sodium = 1 level teaspoon of table salt
  • At least 30 min 4 times / Week
    Only walking, jogging or
    non competetive swimming
  • HTN in DM:4- Therapy
    Life Style Modifications
  • HTN in DM:4- Therapy
    Life Style Modifications
  • Goal Blood Pressure
    Life Style Modification
    Drug Therapy
  • Goal Blood Pressure
    Life Style Modification
    Drug Therapy
  • The need of multiple drugs.
    Best drug for compelling indications.
    Critical contraindications of anti HTN drugs.
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Drug Therapy: Need for Multiple Drugs
    No. of antihypertensive agents
    Target BP (mm Hg)
    Trial
    1
    2
    3
    4
    UKPDS DBP &lt;85
    ABCD DBP &lt;75
    MDRD MAP &lt;92
    HOT DBP &lt;80
    AASK MAP &lt;92
    IDNT SBP &lt;135/DBP &lt;85
    ALLHAT SBP &lt;140/DBP &lt;90
    DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.
    Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.
    Lewis EJ et al. N Engl J Med. 2001;345:851-860.
    Cushman WC et al. J Clin Hypertens. 2002;4:393-404.
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Drug Therapy: Compelling Indications
    2003 WHO/ ISH Statement on Hypertension
  • 2003 WHO/ ISH Statement on Hypertension
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Practical View
    Pts. At goal BP &lt; 130 / 80
    LSM / Recheck
    2. Pts. with BP 130-139 / 80-89
    LSM /3m  Drug Th
    3. Pts. With BP ≥ 140 /90
    LSM + Drug Th
    4. Pts. With BP &gt; 150 /90
    LSM +2 Drug Th
    If Compelling Indications  Treat accordingly
  • Recommended Drug Therapy
  • First-line Thearpy:
    • ACE-I: Once daily
    • Exceptions to this are:
    People of African-Caribbean descent : ACE-I + D or ACE-I + CCBs
    Women “possibility of becoming pregnant”: CCBs.
    • If intolerance to an ACE-I (other than renal deterioration or hyperkalaemia): ARBs.
    The National Institute for Health and Clinical Excellence (NICE) 2008
  • Second-line Therapy:
    Calcium channel blocker or a diuretic (usually bendroflumethiazide, 2.5 mg daily).
    Add the other drug (that is, the calcium channel blocker or diuretic) if the target is not reached with dual therapy.
    Third-line Therapy:
    Alpha-blocker, a beta-blocker or a potassium-sparing diuretic (the last with caution if the individual is already taking an ACE inhibitor or an angiotensin II-receptor antagonist).
     
    The National Institute for Health and Clinical Excellence (NICE) 2008
  • ACE-I & ARBs
    Can we add ARBs to ACE-I ??
    Hyperkalemia ??
    Cough ??
    Renal impairment ??
    Direct anti renin ??
  • RASILEZ
  • Management of Hypertension in Diabetics
    Drug Considerations: CCBs
    If d-CCB Chosen: Not to be used without ACEi or ARB agents.
    Short-acting d-CCB should not be used in IHD
    because of their potential to increase risk of mortality, particularly in the setting of acute myocardial infarction
  • Management of Hypertension in Diabetics
    Drug Considerations: BBs
    Beta Blockers
    Less appealing as first-line agents for treatment of HTN in DM 1 or 2 (grade A).
    Have proved effective in the management of the ischemic and congestive cardiomyopathies that are more common in patients with diabetes than in those without diabetes.
    Because the major adverse effects of BBs may be mediated by peripheral vasoconstriction and increasing insulin resistance, the use of the new third-generation BBs (such asNebivolol) or drugs that block both a and b receptors (such asCarvedilol) may prove to be particularly beneficial (grade A).
    These agents cause vasodilatation and an increase in insulin sensitivity.
    American Association of Clinical Endocrinologist, 2006
  • Management of Hypertension in Diabetics
    Nebivolol: 3rd generation BB
  • Management of Hypertension in Diabetics
    Drug Considerations: Diuretics
    If Diuretic Chosen:
    Creatinine &lt;1.8 mg/dL Thiazide Diuretic
    Creatinine ≥1.8 mg/dL Loop Diuretic
    If a diuretic is not used in 2 drug therapy, it should included in triple therapy.
  • Management of Hypertension in Diabetics
    Drug Considerations:Anti-Proteinuric
    Type 1: ACE-I
    Type 2: ACE-i or ARBs as a first line.
    Second-line (unable to tolerate ACEi or ARBs: Verapamil or diltiazem.
    BB is a potent antiproteinuric.
  • Management of Hypertension in Diabetics
    HTN in DM:4- Therapy
    Resistant Hypertension
  • Anti Hypertensive Drugs
  • Anti Hypertensive Drugs
  • Anti Hypertensive Drugs
  • Anti Hypertensive Drugs
  • Anti Hypertensive Drugs
  • Thanks
  • ALLHAT--the &quot;Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial“.
    LIFE: Losartan Intervention For Endpoint .
    CAPP: Captopril Prevention Project
    ABCD: Appropriate Blood Pressure Control in Diabetes
    MDRD: Modification of Diet in Renal Disease
    AASK: African American Study of Kidney Disease and Hypertension
  • antihypertensivetreatment with indapamide (sustained release), with or withoutperindopril, in persons 80 years of age or older is beneficia
    N Engl J Med. 2008 May 1;358(18):1887-98