Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.

Management of hypertension in diabetes

18,337 views

Published on

Published in: Health & Medicine

Management of hypertension in diabetes

  1. 1. Dr Mohamed Al-Ameen Nephrology& Transplantation Specialist KAAH&OC
  2. 2. • HTN is the leading cause of morbidity and mortality worldwide. • Affecting 20–60% of diabetics. • HTN is common in Diabetics vs in Non diabetics 1.5 to 3 times. Management of Hypertension in Diabetics HTN in DM:HTN in DM: FactsFacts
  3. 3. • Hypertensive Diabetics vs Hypertensive non diabetics  Twice the risk of CVD • 1 in every 4 individuals in US has HTN. ADA 2005 • The greatest reduction in cardiovascular mortality occurs at achieving a diastolic blood pressure of ~80 mmHg and systolic blood pressure to <130 mmHg Management of Hypertension in Diabetics HTN in DM:HTN in DM: FactsFacts
  4. 4. IHD Mortality Rate in each age dacade vs HTNIHD Mortality Rate in each age dacade vs HTN HTN in DM:HTN in DM: FactsFacts Management of Hypertension in Diabetics
  5. 5. WHOWHO FactFact SheetSheet WorldWorld KSAKSA 20002000 20302030 20002000 20302030 DMDM 171,000,000171,000,000 366,000,000366,000,000 890,000890,000 2,523,0002,523,000  USA: o ~ 60% of Diabetics are HTN. o14% of Af. Am. have HTN& DM ADA 2005 1,513,8001,513,800543,000543,000219,600,000219,600,000102,600.000102,600.000 EstimatedEstimated DM+HTNDM+HTN 1,513,8001,513,800543,000543,000219,600,000219,600,000102,600.000102,600.000 EstimatedEstimated DM+HTNDM+HTN  Germany: o 50% of 1ry care pts have HTN. o 12% of all pts have HTN& DM. Lehnert H et al. 2005Lehnert H et al. 2005 133,800,000 801,880NOW Management of Hypertension in Diabetics HTN in DM:HTN in DM: PrevalencePrevalence
  6. 6. WHOWHO FactFact SheetSheet WorldWorld KSAKSA 20002000 20302030 20002000 20302030 DMDM 171,000,000171,000,000 366,000,000366,000,000 890,000890,000 2,523,0002,523,000  USA: o One in every four has HTN. o ~ 60% of Diabetics are HTN. ADA 2005  Germany: o 50% of 1ry care pts have HTN. o 12% of all pts have HTN&DM. Lehnert H et al. 2005Lehnert H et al. 2005 Management of Hypertension in Diabetics HTN in DM:HTN in DM: PrevalencePrevalence 133,800,000 801,880NOW Only 25 percent of patients with hypertension have adequate control of their blood pressure The Third National Health and Nutrition Evaluation SurveyThe Third National Health and Nutrition Evaluation Survey (NHANES III)(NHANES III) • 29% of diabetic individuals with hypertension were unaware29% of diabetic individuals with hypertension were unaware of the diagnosis.of the diagnosis. • 43% of diabetic individuals with hypertension were untreated.43% of diabetic individuals with hypertension were untreated. • 55% of diabetic individuals on treatment had a blood pressure55% of diabetic individuals on treatment had a blood pressure ≥140/90.≥140/90. • 12% of diabetic individuals on treatment had a blood pressure12% of diabetic individuals on treatment had a blood pressure <130/85.<130/85. Am J Prev Med 22:42–48, 2002
  7. 7. NEJM 2000; 342:905 Diabetes Care 2005; 28:310 Am J Kid Dis 2007; 49 (Suppl 2):S74 HypertensiveHypertensivePopulationsPopulations 95%95%-- MacroalbuminuriaMacroalbuminuria 80%80%-- MicroalbuminuriaMicroalbuminuria 50%50%-- AtAt DxDx •• Type 2 DMType 2 DM 80%80%-- MacroalbuminuriaMacroalbuminuria 40%40%-- MicroalbuminuriaMicroalbuminuria 30%30%-- NormoalbuminuriaNormoalbuminuria •• Type 1 DMType 1 DM 60%60%Diabetic U.S. adultsDiabetic U.S. adults 30%30%All U.S. adultsAll U.S. adults HypertensiveHypertensivePopulationsPopulations 95%95%-- MacroalbuminuriaMacroalbuminuria 80%80%-- MicroalbuminuriaMicroalbuminuria 50%50%-- AtAt DxDx •• Type 2 DMType 2 DM 80%80%-- MacroalbuminuriaMacroalbuminuria 40%40%-- MicroalbuminuriaMicroalbuminuria 30%30%-- NormoalbuminuriaNormoalbuminuria •• Type 1 DMType 1 DM 60%60%Diabetic U.S. adultsDiabetic U.S. adults 30%30%All U.S. adultsAll U.S. adults Type 1Type 1 (¼ are Htn)(¼ are Htn) At Diagnosis: 20-40%At Diagnosis: 20-40% With Microalbuminuria: 30-50%With Microalbuminuria: 30-50% With Macroalbuminuria: 65-88%With Macroalbuminuria: 65-88% Type 2Type 2 (½ are Htn)(½ are Htn) At Diagnosis: 50%At Diagnosis: 50% With Microalbuminuria: 80%With Microalbuminuria: 80% With Macroalbuminuria: >90%With Macroalbuminuria: >90% HTN in DM:HTN in DM: PrevalencePrevalence Management of Hypertension in Diabetics
  8. 8. DiabetesDiabetes HypertensionHypertension HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME Management of Hypertension in Diabetics 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
  9. 9.  Cause:Cause: Hypertension is usuallyHypertension is usually renoparenchymalrenoparenchymal in originin origin caused by Or pointing to underlying diabetic nephropathycaused by Or pointing to underlying diabetic nephropathy  Onset:Onset: Typically becomes manifest about the time thatTypically becomes manifest about the time that patients developpatients develop microalbuminuriamicroalbuminuria.. American Diabetic Association.American Diabetic Association. DiabDiab Care 2004Care 2004  Cause:Cause: Mainly due insulin resistance (as a facet of MS)Mainly due insulin resistance (as a facet of MS) But may be due to underlying DN or other causes.But may be due to underlying DN or other causes. American Diabetic Association. Diab Care 2004  Onset:Onset: Usually precedes the onset of nephropathy andUsually precedes the onset of nephropathy and even the onset of type 2 diabetes by years or decadeeven the onset of type 2 diabetes by years or decade  Ritz et al. J Int Med. 2001 ; 249: 215Ritz et al. J Int Med. 2001 ; 249: 215--223223 DM-2DM-2 DM-1DM-1 DiabetesDiabetes HypertensionHypertension HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME Management of Hypertension in Diabetics
  10. 10. DiabetesDiabetes HypertensionHypertension Hypertensive patients without diabetes tend to be resistant to insulin and are hyperinsulinaemic compared with normotensive controls. Pollare T et al. Metabolism 1990, 39(2):167-174. About 20% of patients with hypertension will develop type 2 diabetes in a three year period. Bosch J et al. N Engl J Med 2006, 355(15):1551-1562. Fasting glucose levels increase in older adults with hypertension regardless of treatment type. BarzilayJ I et al. Arch Intern Med. 2006;166:2191- 2201  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. Jandeleit-Dahm KA et al. J Hypertens 2005, 23(3):463-473.  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. Ferrannini E et al. Diabetologia 2003, 46(9):1211-1219. HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME Management of Hypertension in Diabetics
  11. 11. DiabetesDiabetes HypertensionHypertension HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME Management of Hypertension in Diabetics  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. 0 5 10 15 Chlorthalidone Amlodipine Lisinopril 11.6% 9.8% 8.1% ALLHAT: Incidence of New-Onset Diabetes at 4 Years JAMA 2002;288:2981-2997 Role of Antihypertensive Drugs
  12. 12. HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME Management of Hypertension in Diabetics DiabetesDiabetes HypertensionHypertension  Taking a thiazide diuretic, ACETaking a thiazide diuretic, ACE inhibitor, or CCB carry noinhibitor, or CCB carry no greater risk for the subsequentgreater risk for the subsequent development of DM.development of DM.  DM was 28 percent more likelyDM was 28 percent more likely to develop in subjects takingto develop in subjects taking BB than in those taking noBB than in those taking no medication.medication.  This adverse effect of BB mustThis adverse effect of BB must be weighed against the provenbe weighed against the proven benefits of this drug inbenefits of this drug in reducing the risk ofreducing the risk of cardiovascular eventscardiovascular events Role of Antihypertensive Drugs
  13. 13. AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 7 / OCTOBER 1, 2002 Diabetes andDiabetes and HTNHTN vsvs DiabetesDiabetes Relative RiskRelative Risk ofof ComplicationsComplications CHDCHD X 3.0X 3.0 StrokeStroke X 4.0X 4.0 RetinopathyRetinopathy X 2.0X 2.0 NephropathyNephropathy X 2.0X 2.0 NeuropathyNeuropathy X 1.6X 1.6 MortalityMortality X 2.0X 2.0 75% die from CVD75% die from CVD NEJM 2005; 352:341 HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME Management of Hypertension in Diabetics
  14. 14. Association between refractory hypertension and cardiometabolic risk The HIPERFRE study, 2008 1,724 hypertensive patients, 35 physicians, 14 Primary Care Units The HIPERFRE study, 2008 1,724 hypertensive patients, 35 physicians, 14 Primary Care Units Management of Hypertension in Diabetics HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME
  15. 15. D E A T H LDL=low-density lipoprotein; HDL=high-density lipoprotein; MI=myocardial infarction; CHD=congestive heart failiure; HF=heart failure; ESRD=end-stage renal disease Adapted from Arch Intern Med. 2000; 160:1277-1283. Insulin Resistance Hyper- insulinemia Triglycerides LDL HDL Visceral Fat Angiotensin II Sympathetic Activity + Hypertension Diabetes CHD Stroke MI HF ESRD Metabolic Syndrome Morbid States Management of Hypertension in Diabetics HTN in DM:HTN in DM: PARTNERS IN CRIMEPARTNERS IN CRIME
  16. 16. Tight Glucose ControlTight Glucose Control Tight BP ControlTight BP Control **P < 0.05P < 0.05 -50 - -40 - -30 - 0 - Stroke Any DM End Point DM Death Microvascular Complications ReductioninRisk(%) UKPDS. BMJ. 1998:317;703-712. -20 - -10 - Tight BP Control vs. Tight Glucose ControlTight BP Control vs. Tight Glucose Control HTN in DM:HTN in DM: Effect of BP ControlEffect of BP Control
  17. 17. Tight BP Control vs. Tight Glucose ControlTight BP Control vs. Tight Glucose Control HTN in DM:HTN in DM: Effect of BP ControlEffect of BP Control Tight BP Control Tight Glucose Control
  18. 18. 1. Measure BP properly. 2. Define Hypertensive Patients. 3. Evaluate hypertensive Patients. 4. Therapy HTN in DM:HTN in DM: Practical StrategyPractical Strategy
  19. 19. HTN in DM:HTN in DM: 1- Measure BP Properly1- 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) J Hum Hypertens 2008; 22:63 ∆ BP (mm Hg) if not done Rest ≥ 5min, quite ↑ 12/6 Seated, back supported ↑ 6/8 Cuff medsternal level ↑ ↓ 2/inch Correct cuff size ↑ 6-18/3-14 Bladder center over artery ↑ 3-5/2-3 Deflate 2 mm Hg/ sec ↑ SBP/↓ DBP Can J Card 2007; 23:529
  20. 20. HTN in DM:HTN in DM: 1- Measure BP Properly1- Measure BP Properly Joint National CommiteeJoint National Commitee Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. JNC-7 The patient should be seated for at least 5 minutes, relaxed and not moving or speaking. The arm must be supported at the level of the heart. Ensure no tight clothing constricts the arm. Place the cuff on neatly with the centre of the bladder over the brachial artery. The bladder should encircle at least 80% of the arm (but not more than 100%). The column of mercury must be vertical, and at the observers eye level. Estimate the systolic beforehand: a) Palpate the brachial artery b) b) Inflate cuff until pulsation disappears c) Deflate cuff d) Estimate systolic pressure Then inflate to 30 mmHg above the estimated systolic level needed to occlude the pulse. Place the stethoscope diaphragm over the brachial artery and deflate at a rate of 2-3mm/sec until you hear regular tapping sounds. Measure systolic (first sound) and diastolic (disappearance) to nearest 2mmHg.
  21. 21. HTN in DM:HTN in DM: 1- Measure BP Properly1- Measure BP Properly Indications of Ambulatory BP monitoringIndications of Ambulatory BP monitoring JNC-7
  22. 22. Management of Hypertension in Diabetics High Normal BP and CVD Risk HTN in DM:HTN in DM: 22-- Define Hypertensive PatientsDefine Hypertensive Patients Joint National Committee 7 (JNC-7)Joint National Committee 7 (JNC-7)
  23. 23. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 2-2- Define Hypertensive PatientsDefine Hypertensive Patients Systolic or Diastolic Hypertension???????Systolic or Diastolic Hypertension??????? 250 200 150 100 50 0 <120 120-139 140-159 160-179 180-199 Systolic BP (mm Hg)Systolic BP (mm Hg) CV mortality rate/ 10,000 person-yr Nondiabetic Diabetic CV, cardiovascular; SBP, systolic blood pressure. Stamler J et al. Diabetes Care. 1993;16:434-444. ≥200 CV Mortality Risk Doubles WithCV Mortality Risk Doubles With Each 20/10 mm Hg BP Increment*Each 20/10 mm Hg BP Increment* • Stronger predictor of risk than diastolic BP: – Cardiovascular disease – Diabetic Nephropathy • 65% of DM hypertensives have isolated systolic hypertension. • Systolic hypertension more difficult to control 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.
  24. 24. • Diastolic hypertension predominates before age 50, either alone or in combination with SBP elevation. • Systolic hypertension increases with age, and above 50 years of age, systolic hypertension represents the most common form of hypertension. • DBP is a more potent cardiovascular risk factor than SBP until age 50; thereafter, SBP is more important. • DBP control rates exceeded 90 percent, but SBP control rates were considerably less (60–70 percent) J Clin Hypertens 2002;4:393-404. Hypertension 2001;37:12-8. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 2-2- Define Hypertensive PatientsDefine Hypertensive Patients  Three-fourths of 1ry care physicians failed to initiate therapy if SBP 140-159.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 importantMost physicians have been taught that the diastolic pressure is more important than SBP and thus treat accordingly.than SBP and thus treat accordingly.  Most primary care physicians did not pursue control to <140 mmHg.Most primary care physicians did not pursue control to <140 mmHg. J Clin Hypertens. 2000;2:324-30.J Clin Hypertens. 2000;2:324-30. Systolic or Diastolic Hypertension???????Systolic or Diastolic Hypertension???????
  25. 25. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 2-2- Define Hypertensive PatientsDefine Hypertensive Patients Systolic or Diastolic Hypertension???????Systolic or Diastolic Hypertension???????
  26. 26. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 2-2- Define Hypertensive PatientsDefine Hypertensive Patients Normal < 120/<80 Prehypertension 120-139/ 80-89 Stage 1 140-159/ 90-99 Stage 2 ≥ 160/ ≥100 Follow up BP MeasurementsFollow up BP Measurements
  27. 27. • Estimate CV Risk Factors. • Diagnose Target Organ Damage. • Exclude Identifiable Causes of HTN. • Routine Laboratory work up with ECG, lipid profile and urinary albumin. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 3- Evaluate3- Evaluate Hypertensive Pts.Hypertensive Pts.
  28. 28. • HTN* • Age: • Older than 55 years for men • Older than 65 years for women • DM* • Abnormal Lipid Profile*: • Elevated LDL (or total) cholesterol • Low HDL cholesterol* • Estimated GFR <60 mL/min • Family history of premature CVD: • men <55 years of age • women <65 years of age • Microalbuminuria • Obesity* (BMI >30 kg/m2) • Physical inactivity • Tobacco usage, particularly cigarettes Management of Hypertension in Diabetics HTN in DM:HTN in DM: 3- Evaluate3- Evaluate Hypertensive Pts.Hypertensive Pts. Cardiovascular Risk FactorsCardiovascular Risk Factors (140-age) x weight x 1.23 x (0.85 if female)(140-age) x weight x 1.23 x (0.85 if female) S Creatinine (micromol/l)S Creatinine (micromol/l) (140-age) x Weight (Kg) x (0.85 if female)(140-age) x Weight (Kg) x (0.85 if female) 72 x S Creatinine (mg/dl)72 x S Creatinine (mg/dl) Normoalbuminuria < 30 mg/day Microalbuminuria 30 - 300 mg /d Macroalbuminuria > 300 mg / day BMI= Weight (Kg) / (Height in meter)2
  29. 29. • Heart • LVH • Angina/prior MI • Prior coronary revascularization • Heart failure • Brain • Stroke or transient ischemic attack • Dementia • CKD • Peripheral arterial disease • Retinopathy Management of Hypertension in Diabetics HTN in DM:HTN in DM: 3- Evaluate3- Evaluate Hypertensive Pts.Hypertensive Pts. Target Organ DamageTarget Organ Damage
  30. 30. • ABCD diagnosis of 2ry HTN A: Accuracy, Apnea, Aldosteronism B: Bruit, Bad Kidney C: Catecholamines, Coarctation, Cushing's S. D: Drugs, Diet Management of Hypertension in Diabetics HTN in DM:HTN in DM: 3- Evaluate3- Evaluate Hypertensive Pts.Hypertensive Pts. Identifiable Causes of HTNIdentifiable Causes of HTN
  31. 31. 1. Blood Pressure Goal 2. Life Style Modification 3. Phamacological Therapy Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy
  32. 32. • 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:HTN in DM: 4- Therapy4- Therapy Goal Blood PressureGoal Blood Pressure Less Than 130/80
  33. 33. • 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 > 1gm Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Goal Blood PressureGoal Blood Pressure Less Than 130/80 Can We Go to More Lower Target ? IDNT JASN 2005;16(7):2170–2179
  34. 34. • Lowest Systolic Blood Pressure Is Associated with Stroke inStages 3 to 4 Chronic Kidney Disease J Am Soc Nephrol 18: 960–966, 2007 HR of Stroke vs SBP Can We Go to More Lower Target ? Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Goal Blood PressureGoal Blood Pressure Less Than 130/80 20,358 individuals studied, 1549 (7.6%) had CKD
  35. 35. HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style ModificationsLife Style Modifications
  36. 36. InterventionIntervention TargetTarget Reduce foods withReduce foods with added sodiumadded sodium < 2300 mg /day< 2300 mg /day Weight lossWeight loss BMI <25 kg/mBMI <25 kg/m22 Alcohol restrictionAlcohol restriction Less or equal to 2 drinks/dayLess or equal to 2 drinks/day Physical activityPhysical activity at least 30 minutes 4 times/weekat least 30 minutes 4 times/week Dietary patternsDietary patterns DASH dietDASH diet Smoking cessationSmoking cessation Smoke free environmentSmoke free environment Waist CircumferenceWaist Circumference - Europid, Sub-Saharan- Europid, Sub-Saharan African, Middle EasternAfrican, Middle Eastern - South Asian, Chinese- South Asian, Chinese - Japanese- Japanese Men WomenMen Women <94 cm <80 cm<94 cm <80 cm <90 cm <80 cm<90 cm <80 cm <85 cm <90 cm<85 cm <90 cm HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style ModificationsLife Style Modifications
  37. 37. HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style Modifications:Life Style Modifications: DietaryDietary Dietary Sodium Less than 2300mg / day (Most of the salt in food is hidden and comes from processed food) Dietary Potassium If required, daily dietary intake >80 mmol Calcium supplementation No conclusive studies for hypertension Magnesium supplementation No conclusive studies for hypertension • High in fresh fruits • High in vegetables • High in low fat dairy products •High in dietary and soluble fibre •High in plant protein • Low in saturated fat and cholesterol •Low in sodium
  38. 38. • Less than: – 2,300 mg sodium (Na) – 100 mmol sodium (Na) – 5,8 g of salt (NaCl) – 1 teaspoon of table salt 2,300 mg sodium = 1 level teaspoon of table salt HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style Modifications:Life Style Modifications: Daily SodiumDaily Sodium
  39. 39. Exercise should be prescribed as adjunctive to pharmacological therapy Should be prescribed to reduce blood pressure Type cardiorespiratory activity - Walking, jogging - Cycling - Non-competitive swimming Time - 30-60 minutes Intensity - Moderate Frequency - Four to seven days per weekF I T T HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style Modifications:Life Style Modifications: Physical ActivityPhysical Activity
  40. 40. 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 <94 cm <80 cm - South Asian, Chinese <90 cm <80 cm - Japanese <85 cm <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 HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style Modifications:Life Style Modifications: Weight LossWeight Loss
  41. 41. HTN in DM:HTN in DM: 4- Therapy4- Therapy Life Style ModificationsLife Style Modifications InterventionIntervention AmountAmount SBP/DBPSBP/DBP Reduce foods withReduce foods with added sodiumadded sodium - 1800 mg sodium- 1800 mg sodium hypertensivehypertensive -5.1 / -2.7-5.1 / -2.7 Weight lossWeight loss per kg lostper kg lost -1.1 / -0.9-1.1 / -0.9 Alcohol intakeAlcohol intake - 3.6 drinks/day- 3.6 drinks/day -3.9 / -2.4-3.9 / -2.4 Aerobic exerciseAerobic exercise 120-150 min/week120-150 min/week -4.9 / -3.7-4.9 / -3.7 Dietary patternsDietary patterns DASH dietDASH diet HypertensiveHypertensive NormotensiveNormotensive -11.4 / -5.5-11.4 / -5.5 -3.6 / -1.8-3.6 / -1.8
  42. 42. • Use caution in initiating therapy with 2 drugs where agressive blood pressure lowering is more likely or more poorly tolerated (e.g. those with postural hypotension). • ACE inhibitors and ARBs are contraindicated in pregnancy and caution is required in prescribing to women of child bearing potential. • Diuretic-induced hypokalemia should be avoided through the use of potassium sparing agent if required. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Important ConsiderationsImportant Considerations
  43. 43. • Monitor creatinine and potassium when combining K sparing diuretics, ACE inhibitors and/or ARBs. • If Dihydropyridine CCB Chosen: Not to be used without ACEi or ARB agents. • If a diuretic is not used as first or second line therapy, triple drug therapy should include a diuretic, when not contraindicated. • Short-acting dihydropyridine calcium antagonists 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 HTN in DM:HTN in DM: 4- Therapy4- Therapy Important ConsiderationsImportant Considerations
  44. 44. • Beta Blockers – BBs less appealing as first-line agents for treatment of hypertension in patients with either type 2 or type 1 diabetes mellitus (grade A). – BBs, however, 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 as Nebivolol) or drugs that block both a and b receptors (such as Carvedilol) may prove to be particularly beneficial (grade A). – These agents cause vasodilatation and an increase in insulin sensitivity. American Association of Clinical Endocrinologist, 2006 – Beta adrenergic blockers are not recommended for patients age 60+ without another compelling indication. CHEP 2008 Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Important ConsiderationsImportant Considerations
  45. 45. • Beta Blockers (cont.) – Two drug combinations of beta blockers, ACE inhibitors and ARBs have not been proven to have additive hypotensive effects. – Therefore these potential two drug combinations should not be used unless there is a compelling (non blood pressure lowering) indication such as ischemic heart disease, post myocardial infarction, congestive heart failure or chronic kidney disease with proteinuria. – It is not recommended to combine a non dihydropyridine CCB and a beta blocker to reduce the risk of bradycardia or heart block. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Important ConsiderationsImportant Considerations
  46. 46. • If Diuretic Chosen: (Preferred if no other compelling indications): – Creatinine <1.8 mg/dL  Thiazide Diuretic – Creatinine ≥1.8 mg/dL  Loop Diuretic – Max. dose 25mg Hydrochlorothiazide or equivalent) Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Important ConsiderationsImportant Considerations
  47. 47. AASK MAP <92 Target BP (mm Hg) No. of antihypertensive agents 1 UKPDS DBP <85 ABCD DBP <75 MDRD MAP <92 HOT DBP <80 Trial 2 3 4 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. IDNT SBP <135/DBP <85 ALLHAT SBP <140/DBP <90 Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Most Hypertensive Patients Need Multiple DrugsMost Hypertensive Patients Need Multiple Drugs
  48. 48. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Compelling IndicationsCompelling Indications
  49. 49. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy ADA GuidelinesADA Guidelines SystolicSystolic DiastolicDiastolic Goal (mmHg)Goal (mmHg) <130<130 <80<80 Behavioral therapy aloneBehavioral therapy alone 130–139130–139 80–8980–89 (maximum 3 months)(maximum 3 months) then add pharmacologicthen add pharmacologic treatmenttreatment Behavioral therapy +Behavioral therapy + ≥≥140140 ≥≥9090 pharmacologic treatmentpharmacologic treatment Arauz-Pacheco C et al. Diabetes Care. 2003;26(suppl):S80–S82.
  50. 50. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Practical ViewPractical View 1.1. Pts. At goal BP < 130 / 80.Pts. At goal BP < 130 / 80. 2.2. Pts. with BP 130-139 / 80-89.Pts. with BP 130-139 / 80-89. 3.3. Pts. With BP ≥ 140 /90.Pts. With BP ≥ 140 /90. 1 32 Without Compelling Indications With Compelling Indications With Compelling Indications Without Compelling Indications With Compelling Indications Without Compelling Indications - LSM - Recheck each visit - LSM - Recheck each visit - Treat CI -LSM 3 m -- if high BP drug Therapy -LSM -Drug Th of HTN -Drug Th of CI -LSM -Drug Th of HTN -LSM - Drug combined -Drug of CI
  51. 51. ACE -ve or ARB (Or thiazide if no albuminuria or TOD) • Consider two-drug therapy if BPe ≥ 150/90 mmHg ≥ 140/90 Or albuminuria Or TOD ≥ 130/80 mmHg on two visits≤ 1 month apart 130–139/80–89 No albuminuria, No TOD LSM for 3 months ≥ 130/80 mmHg after 1 m Add thiazide (or BID loop diuretic if cr ≥ 1.8 mg/dl or estimated GFR < ml/min/1.73m2) Add nonDHP CCB (verapamil or diltiazem) Substitute DHP CCB for nonDHP CCB • Add B-blocker Add DHP CCB Reassess for causes of resistant hypertension •Add α blocker, hydralazine, clonidine Consider consultation. ≥ 130/80 mmHg after 3 m ≥ 130/80 mmHg after 1 m ≥ 130/80 mmHg after 1 m Algorithm for the Treatment of Hypertension in DMAlgorithm for the Treatment of Hypertension in DM
  52. 52. • In Type 2 patients: ACE-i or ARBs as a first line. • In Type 1 patients: ACE-I is recommended to reduce protein excretion • Consider the use of verapamil or diltiazem in patients with proteinuria unable to tolerate ACEi or ARBs. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy For Pts. With Microalbuminuria or ProteinuriaFor Pts. With Microalbuminuria or Proteinuria
  53. 53. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy ACE-I + ARBs: Limited UtilityACE-I + ARBs: Limited Utility • Theoretically attractive: more complete RAAS blockade • Limited BP ↓ and ↓ CVD events vs ACE-I at max dose – ONTARGET RCT: 25,620 with CVD ± Stroke ± DM – Ramipril vs Telmisartan vs R⊕T • Minimal BP ↓: 2.4/1.4 mm Hg • No ↓ CVD events • More side effects • ↓ Albuminuria 30-40% vs monoRx with ACE-I or ARB – ? Effects on ESRD? – NKF, 2007: consider if albumin/cr > 500 mg/g on monoRx NEJM 2008; 358:1547 Am J Kid Dis 2007; 49(Suppl 2):S74
  54. 54. • • Increased HTN control • • Reduced hypokalemia • • Cardioprotective • • Available as a generic medication • • Increased adherence Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy ACE-I + HCTZ: Excellent 1ACE-I + HCTZ: Excellent 1stst line agentline agent
  55. 55. • Consider continuing the ACE-I: • 38-55% Likelihood the cough will resolve. • Consider changing the time of administration or lowering the dose • Consider antitussives or lozenges while waiting for symptom to resolve. • Consider switching to a 2nd ACE-I: • Effective for 1 in 10 patients • Consider using a different drug class: • Diuretic, beta-blocker or calcium channel blocker • If an ACE-I is indicated because of comorbid conditions (e.g. DM,HF, CKD) an ARB (i.e. LOSARTAN) can be used as an alternative Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy ACE-I CoughACE-I Cough
  56. 56.  ACE-I or ARBs may cause Hyperkalemia: 1. Avoid other medications that cause hyperkalemia (K suppl, NSAIDs, Cox2 inhibitors, K sparing diuretics). 2. Evaluate causes of hyperkalemia. 3. Treat hyperkalemia with diuretics. 4. Continuo ACE-I or ARBs if K < 5.5 mmol/l.  Monitor GFR 1. If GFR >30% within 4 weeks, evaluate. 2. Continuo ACE-I or ARBs if GFR < 30% from baseline over 4 months. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy ACE-I or ARBs and HyperkalemiaACE-I or ARBs and Hyperkalemia
  57. 57. Management of Hypertension in Diabetics HTN in DM:HTN in DM: 4- Therapy4- Therapy Resistant HypertensionResistant Hypertension
  58. 58. ClassClass Drug (Trade Name)Drug (Trade Name) Usual Dose Range in MG/Usual Dose Range in MG/ DAYDAY Thiazide diureticsThiazide diuretics Chlorothiazed (Diuril)Chlorothiazed (Diuril) Chlorthalidone (generic)Chlorthalidone (generic) Hydroclorothiazide (Microzide,Hydroclorothiazide (Microzide, Hydro DIURIL)Hydro DIURIL) Polythiazide (Renese)Polythiazide (Renese) Indapamide (Lozol)Indapamide (Lozol) Metalozol (Mykrox)Metalozol (Mykrox) Metalazone (zaroxolyn)Metalazone (zaroxolyn) 125-500125-500 12.5-2512.5-25 12.5-5012.5-50 2-42-4 1.25-2.51.25-2.5 0.5-1.00.5-1.0 2.5-52.5-5 Loop diureticsLoop diuretics Bumetanide (bumex)Bumetanide (bumex) Furosemide (Lasix)Furosemide (Lasix) Torsemide (Demadex)Torsemide (Demadex) 0.5-20.5-2 20-8020-80 2.5-102.5-10 Potassium-sparingPotassium-sparing diureticsdiuretics Amiloride (Midamor)Amiloride (Midamor) Triamtrene (Dyrenium)Triamtrene (Dyrenium) 5-105-10 50-10050-100 Aldosterone receptorAldosterone receptor blockersblockers Eplernone ( Inspra)Eplernone ( Inspra) Spironolactone (Aldactone)Spironolactone (Aldactone) 50-10050-100 25-5025-50 Anti Hypertensive Drugs
  59. 59. ACE InhibitorsACE Inhibitors Benazepril (Lotensin) captoprilBenazepril (Lotensin) captopril (capoten)(capoten) Enalapril (vasotec)Enalapril (vasotec) Fosinopril (monopril)Fosinopril (monopril) Lisinopril (prinivil, zestril)Lisinopril (prinivil, zestril) Moexipril (Univasc)Moexipril (Univasc) Perindopril (Accupril)Perindopril (Accupril) Quinapril (Accupril)Quinapril (Accupril) Ramipril (Altace)Ramipril (Altace) Trandolapril(Mavik)Trandolapril(Mavik) 10-4010-40 25-10025-100 2.5-402.5-40 10-4010-40 10-4010-40 7.5-307.5-30 4-84-8 10-4010-40 2.5-202.5-20 1-41-4 Angiotensin IIAngiotensin II AntagonistsAntagonists Candesartan (Atacand)Candesartan (Atacand) Eprosartan (Teveltan)Eprosartan (Teveltan) Irbesartan (Avapro)Irbesartan (Avapro) Losartan (Cozaar)Losartan (Cozaar) Olmesartan (Benicar)Olmesartan (Benicar) Telmisartan (Micardis)Telmisartan (Micardis) Valsartan (Diovan)Valsartan (Diovan) 8-328-32 400-800400-800 150-300150-300 25-10025-100 20-4020-40 20-8020-80 80-32080-320 Anti Hypertensive Drugs
  60. 60. Beta-BlockersBeta-Blockers Atenolol (Tenormin)Atenolol (Tenormin) Betaxolol (Kerlone)Betaxolol (Kerlone) Bisoprolol (zebeta)Bisoprolol (zebeta) Metoprolol (lopressor)Metoprolol (lopressor) Metoprolol extended releaseMetoprolol extended release (Toprol XL)(Toprol XL) Nadolol (Corgard)Nadolol (Corgard) Propranolol (Inderal)Propranolol (Inderal) Propranolol long-actingPropranolol long-acting (Inderal LA)(Inderal LA) Timolol (Blocadren)Timolol (Blocadren) 25-10025-100 5-205-20 2.5-102.5-10 50-10050-100 50-10050-100 40-12040-120 40-16040-160 60-18060-180 20-4020-40 Beta-Blockers withBeta-Blockers with intrinsic sypathomimeticintrinsic sypathomimetic activityactivity Acebutolol (Sectral)Acebutolol (Sectral) Penbutolol (Levatol)Penbutolol (Levatol) Pindolol (generic)Pindolol (generic) 200-800200-800 10-4010-40 10-4010-40 Combined Alpha– andCombined Alpha– and beta-blockersbeta-blockers Carvedilol (Coreg)Carvedilol (Coreg) Labetalol (Normodyne)Labetalol (Normodyne) 12.5-5012.5-50 200-800200-800 Anti Hypertensive Drugs
  61. 61. Calcium channelCalcium channel blockers- nonblockers- non DihydropyridinesDihydropyridines Diltiazem extended releaseDiltiazem extended release (cardizem CD, Dilacor XR, Tiazac) Diltiazem(cardizem CD, Dilacor XR, Tiazac) Diltiazem extended release (Cardizem LA)extended release (Cardizem LA) Verapamil immediate release (calan, isoptin)Verapamil immediate release (calan, isoptin) Verapamil long acting (calan SR,Verapamil long acting (calan SR, Isoptin SR)Isoptin SR) Verapamil – Coer (Covera HS, Verelan PM)Verapamil – Coer (Covera HS, Verelan PM) 180-420180-420 120-540120-540 80-32080-320 120-360120-360 120-360120-360 Calcium ChannelCalcium Channel Blockers -Blockers - DihydropyridinesDihydropyridines Amlodipine ( Norvasc )Amlodipine ( Norvasc ) Felodipine (plendil)Felodipine (plendil) Isradipine (Dynaciric CR)Isradipine (Dynaciric CR) Nicardipine sustained release (Cardene SR)Nicardipine sustained release (Cardene SR) Nifedipine long-acting (Adalat CC, procardiaNifedipine long-acting (Adalat CC, procardia XL)XL) Nisoldipine (Sular)Nisoldipine (Sular) 2.5-102.5-10 2.5-202.5-20 2.5-102.5-10 60-12060-120 30-6030-60 10-4010-40 Anti Hypertensive Drugs
  62. 62. Alpha- BlockersAlpha- Blockers Doxazosin ( Cardura)Doxazosin ( Cardura) Prazosin (minipress)Prazosin (minipress) Terazosin (Hytrin)Terazosin (Hytrin) 1-161-16 2-202-20 1-201-20 Central alpha-agonistsCentral alpha-agonists and other centrallyand other centrally acting drugsacting drugs Clonidine (Catapres)Clonidine (Catapres) Clonidine patch (catapres-TTS)Clonidine patch (catapres-TTS) Methyldopa (Aldomet)Methyldopa (Aldomet) Resrpine (generic)Resrpine (generic) Guanfacine (generic)Guanfacine (generic) 0.1-0.80.1-0.8 0.1-0.30.1-0.3 250-1000250-1000 0.05-0.250.05-0.25 0.5-20.5-2 Direct VasodilatorsDirect Vasodilators Hydralazine (Apresoline)Hydralazine (Apresoline) Minoxidil (Loniten)Minoxidil (Loniten) 25-10025-100 2.5-802.5-80 Anti Hypertensive Drugs
  63. 63. Angiotensin II ⇑ AVP ⇑ Aldosterone Vaso- constriction Mesangial Contraction Efferent Constriction CNS Dypsogenia Na + Retention Increased Norepinephrine Release Myocardial Hypertrophy Vessel Hypertrophy Deleterious Effects of Angiotensin IIDeleterious Effects of Angiotensin II Management of Hypertension in Diabetics
  64. 64. JNC-7 Management of Hypertension in Diabetics
  65. 65. Management of Hypertension in Diabetics
  66. 66. American Journal of Kidney Diseases, February 2007 NKF. American Journal of Kidney Diseases, February 2007 Management of Hypertension in Diabetics

×