ADA Offers Position Statement on Diabetes and Hypertension

The American Diabetes Association (ADA) today offered a position statement on treating diabetes and hypertension for the first time since 2003. The statement incorporates findings from several key studies since that time, notably the 2010 ACCORD study (Action to Control Cardiovascular Risk in Diabetes).

The statement, published in the journal Diabetes Care, features recommendations for diagnosing hypertension in patients with diabetes and an algorithm treating them, depending on how elevated their blood pressure is. The authors note that hypertension is a strong risk factor in atherosclerotic cardiovascular disease (ASCVD), heart failure, and microvascular complications that are the hallmarks of advanced diabetes, which contribute to both direct and indirect costs. In 2013, the ADA found that the annual costs of diabetes in the United States totaled $245 billion.

Those with a blood pressure between 140/90 mm Hg and 160/100 mm Hg should start on a single antihypertensive agent, and those with a reading higher than 160/100 mg Hg should immediately start with 2 agents; both groups should improve their lifestyle management. The algorithm goes on to recommend specific agents depending on whether patients meet targets or experience adverse effects.

The guideline continues the advice that most patients with diabetes should be treated to a blood pressure goal of <140/90 mm Hg; a goal of <130/80 can be considered for patients who have other cardiovascular risk factors. This follows results of ACCORD BP, which found no difference in a composite of cardiovascular events for patients whose blood pressure was treated to a much lower target of 120/80 mm Hg, although some noted there was a reduction in strokes.

By contrast, a trial involving patients with cardiovascular risks who did not have diabetes, the SPRINT trial, was stopped early in 2015 when it was clear the lower target of 120/80 mm Hg brought substantial benefits. For patients with diabetes and blood pressure >120/80 mm Hg, the statement calls for lifestyle management to promote weight loss if the patient is overweight or obese, including increased fruit and vegetable consumption, limiting sodium intake to <2300 mg/day, moderation of alcohol use, and more exercise.

The statement details the steps for diagnosing hypertension, including a recommendation for home blood pressure monitoring if “white coat” hypertension is suspected. In fact, the statement promotes home monitoring to encourage patient engagement and treatment adherence.

Treatment should include drug classes with demonstrated cardiovascular benefits in patients with diabetes: diuretics, angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), but never these in combination; and dihydropyridine calcium channel blockers. For patients taking ACE inhibitors, ARBs, and diuretics, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored.

Resistant hypertension can be treated with 3 agents, including a diuretic. These patients should be referred to a specialist; if they are still unable to meet goal, mineralocorticoid receptor antagonist therapy should be considered.

“Treatment should be individualized to the specific patient based on their comorbidities; their anticipated benefit for reduction of ASCVD, heart failure, progressive diabetic kidney disease, and retinopathy events, and their risk of adverse events,” the statement says. “This conversation should be part of a shared decision-making process between the clinician and the individual patient.”

Reference

De Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association [published online August 22, 2017]. Diabetes Care. 40:1273—1284 | https://doi.org/10.2337/dci17-0026.