Susan
H is a 20 year old woman with a 5-year history of type 1 diabetes. Her
diabetic control was fairly erratic while she was a teenager but she seems to
be taking better care of herself now. She is seen in the intensive diabetes
clinic and is considering an insulin pump. She sees you for a possible urinary
tract infection.
Her blood pressure is noted to be 142/88mmHg. and you note that her blood
pressure was elevated on her last 3-4 visits. After treating her UTI and
working up her hypertension she is found to have microalbuminuria, you would:
1.
Begin treatment of her hypertension with an ACE-inhibitor.
2.
Start treatment with beta-blocker/thiazide combination.
3.
Institute non-pharmacological interventions for her hypertension.
4.
See her back in 6 months to review her blood pressure.
While
it is important to establish a correct diagnosis of hypertension prior to
starting treatment the history in this case shows Susan has been hypertensive
for some months. Non pharmacologic interventions alone in this scenario are
inappropriate as Susan needs treatment directed both to her hypertension and
microalbuminuria. Therapy with an angiotensin converting enzyme inhibitor is
appropriate in people with Type 1 diabetes with proteinuria secondary to their
potential benefits on renal function. (See JNC VI) The combination of a
thiazide and beta-blocker may lead to deterioration in glucose levels and
monotherapy should be tried first.
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