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Position Statement by the American Diabetes Association: Diabetes and Hypertension

Updated blood pressure control numbers may have cardiovascular benefits for some patients.

From 2000 to 2012, the American Diabetes Association reported that approximately 71% of patients with diabetes had a blood pressure ≥ 140/90 mmHg or were taking medications to help manage their blood pressure. Diabetes and hypertension are interrelated diseases that significantly increase a person’s risk for atherosclerotic cardiovascular disease. Hypertension increases a person’s risk of heart attack, stroke, kidney disease and other health problems. Patients with diabetes are already at an increased risk for these complications and considering hypertension is twice as prevalent in patients with diabetes as in those without, it is imperative that a patient’s blood pressure is well-controlled. The American Diabetes Association recently published a Position Statement intended to update the assessment and treatment of hypertension among individuals with diabetes. This is the first statement released on this topic since 2003 and includes recommendations based on evidence from the SPRINT and ACCORD trials.

While some recommendations have changed, many have remained the same. Blood pressure should continue to be measured at every office visit with any reading ≥ 140/90 mmHg confirmed by multiple readings on separate visits. All patients with diagnosed hypertension should have a home blood pressure monitor and should be encouraged to record their readings daily. Most patients with type 2 diabetes should be treated to obtain a blood pressure ≤ 140/90 mmHg. Although, patients at higher risk of cardiovascular disease may be treated to a blood pressure ≤ 130/80 mmHg, so long as it does not cause harm to the patient. According to the SPRINT trial, patients who achieved a mean SBP < 120 mmHg saw a significant reduction (25%) in myocardial infarction, acute coronary syndrome, stroke, heart failure and death. It should be noted that more stringent blood pressure control was associated with electrolyte abnormalities and increased risk of acute kidney injury in some trial participants. Patients with blood pressure between 140/90 mmHg and 159/99 mmHg should begin pharmacologic therapy in addition to lifestyle modification. In the presence of microalbuminuria, the use of an ACEI or ARB is recommended; for patients with macroalbuminuria, it is strongly recommended that the patient be initiated on an ACEI or ARB. For patients with blood pressure between 140/90 mmHg and 159/99 mmHg without albuminuria, initial treatment of hypertension should include drug classes that are proven to reduce cardiovascular events in patients with diabetes such as: ACEIs, ARBs, dihydropyridine CCBs and thiazide-like diuretics. Lifestyle modifications include weight reduction, restricting sodium intake (< 2,300 mg/day), adapting the DASH diet and moderate-intensity exercise for 30-45 minutes 5 days per week. Smoking cessation, limiting alcohol consumption, and increasing consumption of fruits and vegetables is also strongly recommended.

Previously, it had been suggested that normotensive patients with microalbuminuria could begin treatment with an ACEI or ARB. However, two trials studying the effects of RAS inhibitors in patients without hypertension or albuminuria demonstrated that the use of ACEIs or ARBs did not prevent the development of diabetic kidney disease. Therefore, antihypertensive treatment is not recommended in patients without hypertension or macroalbuminuria. Patients with blood pressure ≥ 160/100, in addition to lifestyle modifications, should be initiated on two medications; ACEI or ARB with CCB or thiazide-like diuretic. Pregnant patients with pre-existing hypertension and diabetes with a blood pressure < 160/105 mmHg with no evidence of end-organ damage should not be treated with pharmacologic therapy. For women requiring antihypertensive therapy blood pressure goals are 120-160/80-105 mmHg; lower blood pressure goals have been associated with impaired fetal growth.

The chief scientific, medical and mission officer for the American Diabetes Association, Dr. William Cefalu, stated that the decrease in atherosclerotic CVD morbidity and mortality in patients with diabetes over the last two decades is likely due to advances in blood pressure control. It is imperative that healthcare providers and diabetes educators stay up-to-date with current treatment guidelines. Controlling blood pressure is one likely way to improve cardiovascular health and limit complications in patients with diabetes.

Watch Diabetes in Control Board Member George Bakris as he talks about high blood pressure and diabetes in relation to kidney disease in this 2017 ADA interview.

Practice Pearls:

  • The use of ACEIs or ARBs in normotensive patients with microalbuminuria is not recommended to prevent the development of diabetic kidney disease.
  • Pregnant patients with no evidence of end-organ disease and blood pressure < 160/105 should not be treated with antihypertensives.
  • Most patients should be treated to a blood pressure < 140/90, although if safe to do so, a goal of 130/80 is appropriate for some patients with diabetes and may show increased cardiovascular benefit.

References:

de Boer, Ian H., et al. “Diabetes and Hypertension: A Position Statement by the American Diabetes Association.” Diabetes Care 40.9 (2017): 1273-1284.

Epstein M, Sowers JR. Diabetes mellitus and hypertension. Hypertension. 1992;19:403-418.

The National High Blood Pressure Education Program Working Group. National High Blood Pressure Education Program Working Group report on hypertension in diabetes. Hypertension. 1994;23:145-158.

Jessica Lambert University of South Florida College of Pharmacy, Doctor of Pharmacy Candidate 2018