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Management Of Hypertension in diabetes- 2009

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presented in endocrinology conference, Jeddah October 2009.

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Management Of Hypertension in diabetes- 2009

  1. 1. Management of <br />Hypertension<br />in Diabetes-2009<br />Dr Mohamed Al-Ameen<br />Nephrologist & Transplant Physician<br />KAAH&OC- Jeddah<br />
  2. 2. بسم الله الرحمن الرحيم<br />
  3. 3. 1.5 billions<br />
  4. 4.
  5. 5. Over 1.5 billion people worldwide<br /> are hypertensive<br />Or 1 in 3 adult<br />
  6. 6. &gt; 7 Millions<br />
  7. 7.
  8. 8. Hypertension<br />7 million deaths/ year<br />
  9. 9. 171,000,000<br />Prevalence of DM worldwide “2000”<br />366,000,000<br />Prevalence of DM worldwide “2030”<br />Prevalence of DM KSA “2000”<br />890,000<br />Prevalence of DM KSA “2030”<br />2,523,000<br />e DM + HTN KSA “2000”<br />543,000<br />e DM + HTN KSA “2030”<br />1,513,800<br />
  10. 10. Dark Numbers<br />171,000,000<br />Prevalence of DM worldwide “2000”<br />366,000,000<br />Prevalence of DM worldwide “2030”<br />Prevalence of DM KSA “2000”<br />890,000<br />Prevalence of DM KSA “2030”<br />2,523,000<br />e DM + HTN KSA “2000”<br />543,000<br />e DM + HTN KSA “2030”<br />1,513,800<br />
  11. 11. The Third National Health and Nutrition Evaluation Survey (NHANES III) <br /><ul><li>About HTN in Diabetic Pts:
  12. 12. 29% unaware about that diagnosis.
  13. 13. 43% untreated.
  14. 14. 65% uncontrolled (≥140/90).
  15. 15. Only 12% had BP <130/85.</li></ul>Am J Prev Med 22:42–48, 2002 Hypertension 52:818-827, 2008<br />
  16. 16. Management of Hypertension in Diabetics<br />Hypertension in Diabetes<br />Prevalence<br />NEJM 2000; 342:905 DiabetesCare 2005; 28:310 AmJKidDis 2007; 49 (Suppl 2):S74<br />
  17. 17.
  18. 18. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />Diabetes<br />Hypertension<br /> HTN vs No HTN DM vs No DM<br /> 2.4x ↑ in DM 2.0x ↑ in HTN<br /> NEJM 2000; 342:905 Diabetes Care 2005; 28:310<br />
  19. 19. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />NEJM 2005; 352:341<br />AMERICAN FAMILY PHYSICIAN www.aafp.org/afp VOLUME 66, NUMBER 7 / OCTOBER 1, 2002<br />
  20. 20. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />“Refractory HTN”<br />The HIPERFRE study, 2008<br />The HIPERFRE study, 2008<br />1,724 hypertensive patients, 35 physicians, 14 Primary Care Units<br />1,724 hypertensive patients, 35 physicians, 14 Primary Care Units<br />Association between refractory hypertension and cardiometabolic risk<br />
  21. 21. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />Diabetes<br />Hypertension<br />Cause: Mainly renoparenchymal and pointing to DN<br />Onset: Typically with microalbuminuria<br />American diabetic association, Diab Care 2004<br />DM-1 <br />Cause: Mainly Insulin Resistance as a facet of MS.<br />Onset: with onset of Diabetes or may precede that by Ys.<br />Ritz et al. J Int Med.2001;249: 215-223.<br />DM-2 <br />
  22. 22. Kidney<br />Disease<br />DM-1 <br />Metabolic Syndrome<br />HTN<br />DM-2 <br />
  23. 23. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />So,<br />The pathogenesis of development is distinct in each type<br />BUT<br />The pathogenesis of marked enhancement of the already high risk of cardiovascular and renal disease in types 1 and 2 are similar in both<br />Landsberg L, Molitch M. Clin Exp Hypertens 2004 Oct-Nov;26(7-8):621-8.<br />
  24. 24. Management of Hypertension in Diabetics<br />Diabetes<br />Hypertension<br />Studies<br />1- Pollare T et al. Metabolism 1990, 39(2):167-174 :<br />There are resistance to insulin and hyperinsulinemia: in hypertensive pts non diabetic compared with normotensive controls. <br />2- Bosch J et al. N Engl J Med 2006, 355(15):1551-1562:<br />About 20% of patients with hypertension will develop type 2 diabetes in a three year period<br />3- BarzilayJ I et al. Arch Intern Med. 2006;166:2191-2201:<br />Fasting glucose levels increase in older adults with hypertension <br />regardless of treatment type.<br />
  25. 25. Management of Hypertension in Diabetics<br />Diabetes<br />Hypertension<br />Studies<br />4- Jandeleit-Dahm KA et al. J Hypertens 2005, 23(3):463-473 :<br />- The RAS itself plays imp. role in the development of diabetes.<br />- 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.<br />5- Ferrannini E et al. Diabetologia 2003, 46(9):1211-1219:<br /> 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.<br />
  26. 26. Diabetes<br />Hypertension<br />Drugs<br />Elliott WJ, Meyer PM: anetwork meta-analysis. Lancet 2007, 369(9557):201-207.<br />
  27. 27. Diabetes<br />Hypertension<br />Drugs<br /> Gupta AK et al.  Diabetes Care. 2008 May;31(5):982-8.<br />
  28. 28. Management of Hypertension in Diabetics<br />Diabetes<br />Hypertension<br />Drugs<br />Role of Antihypertensive Drugs<br />11.6%<br /><ul><li>The risk of diabetes associated </li></ul> with antihypertensive-drug therapy <br /> appears to be explained by the <br /> presence of hypertension.<br /><ul><li>Among the subjects who had </li></ul> hypertension, the risk among those <br /> not taking medication was similar to <br /> that among those taking one or <br /> more agents.<br /><ul><li>Among the subjects who were not </li></ul> taking any antihypertensive <br /> medication, the risk of diabetes <br /> was much higher among <br /> hypertensive Pts. than in non <br /> hypertensive.<br />9.8%<br />8.1%<br />Chlorthalidone<br /> Amlodipine<br />Lisinopril <br />ALLHAT: Incidence of New-Onset Diabetes at 4 Years<br />JAMA 2002;288:2981-2997<br />Gress TW et al. N Engl J Med. 2000 Mar 30;342(13):905-12.<br />
  29. 29. Management of Hypertension in Diabetics<br />Diabetes<br />Hypertension<br />Drugs<br />Role of Antihypertensive Drugs<br /><ul><li> DM was 28 percent more likely </li></ul> to develop in subjects taking <br /> BB than in those taking no <br /> medication.<br /><ul><li> This adverse effect of BB must </li></ul> be weighed against the proven <br /> benefits of this drug in reducing <br /> the risk of cardiovascular events <br />
  30. 30. This adverse effect of BB must <br /> be weighed against the proven <br /> benefits of this drug in reducing <br /> the risk of cardiovascular events <br />
  31. 31. Diabetes<br />Hypertension<br /> Risk<br />Verdecchia P et al. Hypertension. 2004;43:963-969.<br />
  32. 32. Diabetes<br />Hypertension<br />Predictors<br />
  33. 33. Diabetes<br />Hypertension<br />Prevention<br />Screen for NOD in hypertensive Pts. As they share common etiological factors. <br />Use of drugs that inhibit RAS.<br />LIFE, ALLHAT and CAPP.<br />Fixed dose combination ACE-I + CCB (Trandolapril + Verapamil): lower risk of NOD<br />Cheung BM. Diabetes Care. 2008 Sep;31(9):1889-91.<br />Bakris G et al. Diabetes Obes Metab. 2008 Jun 16<br />
  34. 34. Any 3 of the following 5 features<br />Central obesity<br />􀂄 apple vs pear shape<br />Elevated TG<br />Low HDL-cholesterol<br />Elevated blood pressure<br />Elevated fasting plasma glucose or previously undiagnosed type 2 diabetes<br />Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />
  35. 35. Any 3 of the following 5 features<br />Central obesity<br />􀂄 apple vs pear shape<br />Elevated TG<br />Low HDL-cholesterol<br />Elevated blood pressure<br />Elevated fasting plasma glucose or previously undiagnosed type 2 diabetes<br />Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />
  36. 36. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />Criteria of MS<br />Central obesity: Waist circumference<br />􀂄 &gt; 40 inches (men)<br />􀂄 &gt; 35 inches (women)<br />Elevated Triglycerides<br />􀂄 &gt; 150 mg/dl or on TG therapy<br />Low HDL-cholesterol<br />􀂄 &lt; 40 (men)<br />􀂄 &lt; 50 (women)<br />􀂄 Or on therapy to increase HDL-cholesterol<br />
  37. 37. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />Criteria of MS<br />Elevated blood pressure<br />&gt; 130/85 mmHg or on bp therapy<br />Elevated fasting plasma glucose<br />Fasting glucose &gt; 100 mg/dl or<br />Previously undiagnosed type 2 diabetes<br />Fasting glucose &gt; 126 mg/dl on 2 separate occasions<br />
  38. 38. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />Risk of MS<br />Heart Disease<br />Type 2 Diabetes<br />Polycystic Ovarian Syndrome<br />Kidney Disease<br />2.5 fold increase of microalbuminuria<br />3.5 fold increase of chronic kidney disease<br />Cancer<br />Nonalcoholic steatohepatitis<br />Alzheimer’s<br />
  39. 39. Management of Hypertension in Diabetics<br />HTN in DM:PARTNERS IN CRIME<br />
  40. 40. Effect of Tight<br />Control of <br />Blood Pressure<br />
  41. 41. Management of Hypertension in Diabetics<br />HTN in DM:Effect of BP Control<br />Tight BP Control vs. Tight Glucose Control<br />Microvascular<br />Any DM <br />Stroke<br />DM Death<br /> Complications<br />End Point<br />0 -<br />-10 -<br />-20 -<br />Reduction in Risk (%)<br />-30 -<br />Tight Glucose Control<br />-40 -<br />Tight BP Control<br />*P &lt; 0.05<br />-50 -<br />UKPDS. BMJ. 1998:317;703-712.<br />
  42. 42. Management of Hypertension in Diabetics<br />HTN in DM:Effect of BP Control<br />Tight BP Control vs. Tight Glucose Control<br />Whelton, P. K. et al. JAMA 2002;288:1882-1888<br />
  43. 43. Management of Hypertension in Diabetics<br />HTN in DM:Effect of BP Control<br />Tight BP Control vs. Tight Glucose Control<br />Tight BP Control<br />Tight Glucose Control<br />
  44. 44. Management of Hypertension<br />In Diabetes<br />
  45. 45. 636 pts. 24 months<br />4 groups:<br />Usual care.<br />Behavioral intervention (bimonthly tailored nurse-administered telephone intervention targeting hypertension-related behaviors.<br />Home BP monitoring.<br />Combined behavioral intervention plus home BP monitoring.<br />
  46. 46. <ul><li> HOME BP MONITORING
  47. 47. WEB TRAINING
  48. 48. PHARMACIST CARE INTERVENTION</li></li></ul><li>Educational interventions directed to the patient. <br />Educational interventions directed to the health. professional.<br />Health professional (nurse or pharmacist) led care. <br />Appointment reminder systems.<br />
  49. 49. Home BP Monitoring<br />Behavioral intervention<br />Web Training<br />Pharmacist Care <br />Appointment reminder systems<br />
  50. 50. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  51. 51. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  52. 52. HTN in DM: 1- Measure BP Properly<br />The measurement of BP is likely the clinical procedure of greatest importance that is performed in the sloppiest manner.” <br />(Norman Kaplan, M.D.)<br />Lancet 2007; 370:591<br />Health care professionals should take particular care to ensure that they are using accurate techniques to measure BP in all their patients.”<br />(International Working Group, 2008)<br />JHumHypertens 2008; 22:63<br />CanJCard 2007; 23:529<br />
  53. 53. HTN in DM: 1- Measure BP Properly<br />Joint National Commitee<br />Caffeine, exercise, and smoking should be avoided for at least 30 minutes prior to measurement. JNC-7<br />
  54. 54. HTN in DM: 1- Measure BP Properly<br />Joint National Commitee<br />
  55. 55. Mercury Sphygmomanometers<br />What is about automated devices ????????<br />
  56. 56. We recommend that this device not be used when accurate BP measurement is needed for therapeutic decision-making.<br />
  57. 57.
  58. 58.
  59. 59.
  60. 60. HTN in DM: 1- Measure BP Properly<br />
  61. 61. Ambulatory BP monitoring:<br />White Coat HTN with TOD.<br />Episodic HTN<br />Autonomic dysfunction<br />Drug resistance<br />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.<br />HTN in DM: 1- Measure BP Properly<br />
  62. 62. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  63. 63. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  64. 64. Management of Hypertension in Diabetics<br />HTN in DM: 2- Define Hypertensive Patients<br />Joint National Committee 7 (JNC-7)<br />
  65. 65. High Normal BP and CVD Risk<br />
  66. 66.
  67. 67. Management of Hypertension in Diabetics<br />HTN in DM:2- Define Hypertensive Patients<br />Systolic or Diastolic Hypertension???????<br />250<br />Nondiabetic<br />Diabetic<br />200<br />CVmortalityrate/10,000 person-yr<br />150<br />100<br />50<br />0<br />&lt;120<br />120-139<br />140-159<br />160-179<br />180-199<br />≥200<br />Systolic BP (mm Hg)<br />CV, cardiovascular; SBP, systolic blood pressure.<br />Stamler J et al. Diabetes Care. 1993;16:434-444.<br />CV Mortality Risk Doubles WithEach 20/10 mm Hg BP Increment*<br />
  68. 68. Systolic BP is stronger predictor of risk than diastolic BP:<br /><ul><li>Cardiovascular disease
  69. 69. Diabetic Nephropathy</li></ul>65% of DM hypertensives have isolated systolic hypertension.<br />Lancet 2002; 360:1903 Hypertension 2003; 42:1206<br />National Kidney Foundation: Guideline 8. Am J Kidney Dis 43 (Suppl. 1):S142 –S159, 2004.<br /> Sowers JR et al. Hypertension 37:1053 –1059, 2001.<br />
  70. 70. Systolic BP should be the primary target of <br />antihypertensive therapy<br />
  71. 71. Systolic BP represent an important risk factor for CV events which can be prevented or reduced by pharmacological treatment<br />
  72. 72. Management of Hypertension in Diabetics<br />HTN in DM:2- Define Hypertensive Patients<br />Systolic or Diastolic Hypertension???????<br />DBP is a more potent cardiovascular risk factor than SBP until age 50; thereafter, SBP is more important.<br />Diastolic hypertension predominates before age 50, either alone or in combination with SBP elevation.<br />Systolic BP increases with age, and above 50 years of age, systolic hypertension represents the most common form of hypertension.<br />SBP control rates are lower than that of DBP. <br /> J ClinHypertens 2002;4:393-404.<br /> Hypertension 2001;37:12-8.<br />
  73. 73. <ul><li>Three-fourths of 1ry care physicians failed to initiate therapy if SBP 140-159.
  74. 74. Most physicians have been taught that the diastolic pressure is more important than SBP and thus treat accordingly.
  75. 75. Most primary care physicians did not pursue control to <140 mmHg.</li></ul>J ClinHypertens. 2000;2:324-30.<br />
  76. 76. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  77. 77. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  78. 78. Evaluate for:<br />CV Risk Factors.<br />Target Organ Damage.<br />Secondary Causes of HTN.<br />Routine Laboratory work up: eg.. ECG, lipid profile and urinary albumin. <br />Management of Hypertension in Diabetics<br />HTN in DM:3- Evaluate Hypertensive Pts.<br />
  79. 79. HTN<br />DM* <br />Age:<br />Older than 55 years for men<br />Older than 65 years for women<br />Abnormal Lipid Profile*:<br />Elevated LDL (or total) cholesterol<br />Low HDL cholesterol*<br />Estimated GFR &lt;60 mL/min<br />Family history of premature CVD: <br />men &lt;55 years of age<br />women &lt;65 years of age<br />Microalbuminuria<br />Obesity* (BMI &gt;30 kg/m2)<br />Physical inactivity<br />Tobacco usage, particularly cigarettes<br />Management of Hypertension in Diabetics<br />HTN in DM:3- Evaluate Hypertensive Pts.<br />Cardiovascular Risk Factors<br />(140-age) x weight x 1.23 x (0.85 if female)<br />S Creatinine (micromol/l) <br />(140-age) x Weight (Kg) x (0.85 if female)<br /> 72 x S Creatinine (mg/dl)<br />Normoalbuminuria &lt; 30 mg/day<br />Microalbuminuria 30 - 300 mg /d<br />Macroalbuminuria &gt; 300 mg / day<br />BMI= Weight (Kg) / (Height in meter)2<br />
  80. 80. Heart<br />LVH<br />Angina/prior MI<br />Prior coronary revascularization<br />Heart failure<br />Brain<br />Stroke or transient ischemic attack<br />Dementia<br />Kidney: CKD<br />Eye: Retinopathy <br />Vessels: Peripheral arterial disease<br />Management of Hypertension in Diabetics<br />HTN in DM:3- Evaluate Hypertensive Pts.<br />Target Organ Damage<br />
  81. 81. Management of Hypertension in Diabetics<br />HTN in DM:3- Evaluate Hypertensive Pts.<br />2ry Causes of HTN<br />ABCD diagnosis of 2ry HTN<br />A: Accuracy, Apnea, Aldosteronism<br />B: Bruit, Bad Kidney<br />C:Catecholamines, Coarctation, Cushing&apos;s S.<br />D: Drugs, Diet <br />
  82. 82.
  83. 83.
  84. 84.
  85. 85. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  86. 86. HTN in DM:Practical Strategy<br />Measure: Measure BP properly.<br />Define: Define Hypertensive Patients.<br />Evaluate: Evaluate hypertensive pts.<br />Treat: Therapy<br />
  87. 87. Goal Blood Pressure<br />Life Style Modification<br />Drug Therapy<br />
  88. 88. Goal Blood Pressure<br />Life Style Modification<br />Drug Therapy<br />
  89. 89. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Goal Blood Pressure<br />Less Than 130/80<br />HOT (Hypertension Optimal Treatment).<br />ABCD-NT (Appropriate Blood Pressure Control in Diabetes)<br />UKPDS (UK Prospective Diabetes Study)<br />IDNT (Irbesartan in Diabetic Nephropathy Trial)<br />INVEST (International Verapamil-Trandolapril)<br />ADA (American Diabetic association)<br />ISHIB (International Society of Hypertension in Blacks)<br />CHEP (Canadian Hypertension Education Program)<br />BHS (British Hypertension Society) <br />JNC 7 (Joint National Committee 7) <br />
  90. 90. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Goal Blood Pressure<br />Less Than 130/80<br />Can We Go to More Lower Target ?<br />National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis. 2000;36(3):646-661.<br />American Association of Clinical Endocrinologist, 2006<br />Target BP 125/75 If Proteinuria &gt; 1gm<br />IDNT <br />JASN 2005;16(7):2170–2179<br />
  91. 91. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Goal Blood Pressure<br />Less Than 130/80<br />Can We Go to More Lower Target ?<br />20,358 individuals studied, 1549 (7.6%) had CKD<br />HR of Stroke vs SBP<br />Lowest Systolic Blood Pressure Is Associated with Stroke inStages 3 to 4 Chronic Kidney Disease<br />J Am Soc Nephrol18: 960–966, 2007<br />
  92. 92. Lowest Systolic Blood Pressure Is Associated with Stroke in Stages 3 to 4 Chronic Kidney Disease<br />J Am Soc Nephrol18: 960–966, 2007<br />
  93. 93. Goal Blood Pressure<br />Life Style Modification<br />Drug Therapy<br />
  94. 94. Goal Blood Pressure<br />Life Style Modification<br />Drug Therapy<br />
  95. 95. HTN in DM:4- Therapy<br />Life Style Modifications<br />Decrease Weight<br />5-20 mmHg/10 kg<br />Decrease Sodium <br />2-8 mmHg<br />4-9 mmHg<br />Do Ph. Activity<br />8-14 mmHg<br />DASH diet<br />2-4 mmHg<br />Decrease Alcohol <br />Smoke free enviroment<br />D/C Smooking<br />
  96. 96. Hypertensive and all patients<br />BMI over 25 <br />- Encourage weight reduction<br /><ul><li> Healthy BMI: 18.5-24.9 kg/m2</li></ul>Waist Circumference Men Women<br />- Europid, Sub-Saharan African, Middle Eastern &lt;94 cm &lt;80 cm<br />- South Asian, Chinese &lt;90 cm &lt;80 cm<br />- Japanese &lt;85 cm &lt;90 cm<br />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<br />
  97. 97. 2,300 mg sodium = 1 level teaspoon of table salt<br />
  98. 98.
  99. 99. At least 30 min 4 times / Week <br />Only walking, jogging or <br />non competetive swimming<br />
  100. 100.
  101. 101. HTN in DM:4- Therapy<br />Life Style Modifications<br />
  102. 102. HTN in DM:4- Therapy<br />Life Style Modifications<br />
  103. 103. Goal Blood Pressure<br />Life Style Modification<br />Drug Therapy<br />
  104. 104. Goal Blood Pressure<br />Life Style Modification<br />Drug Therapy<br />
  105. 105. The need of multiple drugs.<br />Best drug for compelling indications.<br />Critical contraindications of anti HTN drugs.<br />
  106. 106. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Drug Therapy: Need for Multiple Drugs<br />No. of antihypertensive agents<br />Target BP (mm Hg)<br />Trial<br />1<br />2<br />3<br />4<br />UKPDS DBP &lt;85<br />ABCD DBP &lt;75<br />MDRD MAP &lt;92<br />HOT DBP &lt;80<br />AASK MAP &lt;92<br />IDNT SBP &lt;135/DBP &lt;85<br />ALLHAT SBP &lt;140/DBP &lt;90<br />DBP, diastolic blood pressure; MAP, mean arterial pressure; SBP, systolic blood pressure.<br />Bakris GL et al. Am J Kidney Dis. 2000;36:646-661.<br />Lewis EJ et al. N Engl J Med. 2001;345:851-860.<br />Cushman WC et al. J Clin Hypertens. 2002;4:393-404.<br />
  107. 107. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Drug Therapy: Compelling Indications<br />2003 WHO/ ISH Statement on Hypertension<br />
  108. 108.
  109. 109. 2003 WHO/ ISH Statement on Hypertension<br />
  110. 110. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Practical View<br />Pts. At goal BP &lt; 130 / 80<br />LSM / Recheck<br />2. Pts. with BP 130-139 / 80-89<br />LSM /3m  Drug Th<br />3. Pts. With BP ≥ 140 /90<br />LSM + Drug Th<br />4. Pts. With BP &gt; 150 /90<br />LSM +2 Drug Th<br />If Compelling Indications  Treat accordingly<br />
  111. 111.
  112. 112. Recommended Drug Therapy<br />
  113. 113. First-line Thearpy:<br /><ul><li>ACE-I: Once daily
  114. 114. Exceptions to this are: </li></ul>People of African-Caribbean descent : ACE-I + D or ACE-I + CCBs<br />Women “possibility of becoming pregnant”: CCBs.<br /><ul><li>If intolerance to an ACE-I (other than renal deterioration or hyperkalaemia): ARBs.</li></ul>The National Institute for Health and Clinical Excellence (NICE) 2008<br />
  115. 115. Second-line Therapy: <br />Calcium channel blocker or a diuretic (usually bendroflumethiazide, 2.5 mg daily). <br />Add the other drug (that is, the calcium channel blocker or diuretic) if the target is not reached with dual therapy.<br />Third-line Therapy:<br />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).<br /> <br />The National Institute for Health and Clinical Excellence (NICE) 2008<br />
  116. 116. ACE-I & ARBs<br />Can we add ARBs to ACE-I ??<br />Hyperkalemia ??<br />Cough ??<br />Renal impairment ??<br />Direct anti renin ??<br />
  117. 117.
  118. 118.
  119. 119.
  120. 120.
  121. 121. RASILEZ<br />
  122. 122.
  123. 123. Management of Hypertension in Diabetics<br />Drug Considerations: CCBs<br />If d-CCB Chosen: Not to be used without ACEi or ARB agents.<br />Short-acting d-CCB should not be used in IHD <br />because of their potential to increase risk of mortality, particularly in the setting of acute myocardial infarction<br />
  124. 124. Management of Hypertension in Diabetics<br />Drug Considerations: BBs<br />Beta Blockers<br />Less appealing as first-line agents for treatment of HTN in DM 1 or 2 (grade A). <br />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.<br />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). <br />These agents cause vasodilatation and an increase in insulin sensitivity.<br />American Association of Clinical Endocrinologist, 2006<br />
  125. 125. Management of Hypertension in Diabetics<br />Nebivolol: 3rd generation BB<br />
  126. 126.
  127. 127.
  128. 128. Management of Hypertension in Diabetics<br />Drug Considerations: Diuretics<br />If Diuretic Chosen: <br />Creatinine &lt;1.8 mg/dL Thiazide Diuretic<br />Creatinine ≥1.8 mg/dL Loop Diuretic<br />If a diuretic is not used in 2 drug therapy, it should included in triple therapy.<br />
  129. 129. Management of Hypertension in Diabetics<br />Drug Considerations:Anti-Proteinuric<br />Type 1: ACE-I <br />Type 2: ACE-i or ARBs as a first line.<br />Second-line (unable to tolerate ACEi or ARBs: Verapamil or diltiazem.<br />BB is a potent antiproteinuric.<br />
  130. 130. Management of Hypertension in Diabetics<br />HTN in DM:4- Therapy<br />Resistant Hypertension<br />
  131. 131. Anti Hypertensive Drugs<br />
  132. 132. Anti Hypertensive Drugs<br />
  133. 133. Anti Hypertensive Drugs<br />
  134. 134. Anti Hypertensive Drugs<br />
  135. 135. Anti Hypertensive Drugs<br />
  136. 136. Thanks<br />
  137. 137. ALLHAT--the &quot;Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial“.<br />LIFE: Losartan Intervention For Endpoint .<br />CAPP: Captopril Prevention Project <br />ABCD: Appropriate Blood Pressure Control in Diabetes<br />MDRD: Modification of Diet in Renal Disease <br />AASK: African American Study of Kidney Disease and Hypertension <br />
  138. 138. antihypertensivetreatment with indapamide (sustained release), with or withoutperindopril, in persons 80 years of age or older is beneficia<br />N Engl J Med. 2008 May 1;358(18):1887-98<br />

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