Diabetes

P O S I T I O N

S T A T E M E N T

Hypertension Management in Adults With Diabetes
AMERICAN DIABETES ASSOCIATION

H

ypertension (defined as a blood pressure 140/90 mmHg) is an extremely common comorbid condition in diabetes, affecting 20 – 60% of patients with diabetes, depending on obesity, ethnicity, and age. In type 2 diabetes, hypertension is often present as part of the metabolicsyndrome of insulin resistance also including central obesity and dyslipidemia. In type 1 diabetes, hypertension may reflect the onset of diabetic nephropathy. Hypertension substantially increases the risk of both macrovascular and microvascular complications, including stroke, coronary artery disease, and peripheral vascular disease, retinopathy, nephropathy, and possibly neuropathy. In recentyears, adequate data from welldesigned randomized clinical trials have demonstrated the effectiveness of aggressive treatment of hypertension in reducing both types of diabetes complications. Scope These recommendations are intended to apply to nonpregnant adults with type 1 or type 2 diabetes. Target audience These recommendations are intended for the use of health care professionals who care forpatients with diabetes and hypertension, including specialist and primary care physicians, nurses and nurse practitioners, physicians’ assistants, educators, dietitians, and others.

Method These recommendations are based on the American Diabetes Association Technical Review “Treatment of Diabetes in Adult Patients with Hypertension.” A technical review is a systematic review of the medicalliterature that has been peer-reviewed by the American Diabetes Association’s Professional Practice Committee. Evidence review: hypertension as a risk factor for complications of diabetes Diabetes increases the risk of coronary events twofold in men and fourfold in women. Part of this increase is due to the frequency of associated cardiovascular risk factors such as hypertension, dyslipidemia, andclotting abnormalities. In observational studies, people with both diabetes and hypertension have approximately twice the risk of cardiovascular disease as nondiabetic people with hypertension. Hypertensive diabetic patients are also at increased risk for diabetesspecific complications including retinopathy and nephropathy. In the U.K. Prospective Diabetes Study (UKPDS) epidemiological study, each10-mmHg decrease in mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial infarction, and 13% for microvascular complications. No threshold of risk was observed for any end point.

Evidence for target levels of blood pressure in patients with diabetes The UKPDS and the HypertensionOptimal Treatment (HOT) trial both demonstrated improved outcomes, especially in preventing stroke, in patients assigned to lower blood pressure targets. Optimal outcomes in the HOT study were achieved in the group with a target diastolic blood pressure of 80 mmHg (achieved 82.6 mmHg). Randomized clinical trials demonstrate the benefit of targeting a diastolic blood pressure of 80 mmHg.Epidemiological analyses show that blood pressures 120/70 mmHg are associated with increased cardiovascular event rates and mortality in persons with diabetes. Therefore, a target blood pressure goal of 130/80 mmHg is reasonable if it can be safely achieved. There is no threshold value for blood pressure, and risk continues to decrease well into the normal range. Achieving lower levels, however, would increasethe cost of care as well as drug side effects and is often difficult in practice. Whether even more aggressive treatment would further reduce the risk is an unanswered question, but may be answered by clinical trials now in progress. Evidence for non-drug management of hypertension Dietary management with moderate sodium restriction has been effective in reducing blood pressure in individuals...