Hypertension in Diabetes Mellitus

Aka: Hypertension in Diabetes Mellitus, Diabetes Mellitus Associated Hypertension

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II. Management: Blood Pressure Goal

  1. Continue adding agents until goal reached (2 or 3 at a time are the norm)
  2. Small differences in Blood Pressure (5 mmHg) have large impact on outcomes
  3. Adults: Hypertension goals parallel those for known cardiovascular disease
    1. Blood Pressure target goals are volatile and differ between organizations
      1. ACC/AHA Guidelines are back to <130/80 mmHg for all patients
      2. ADA Guidelines are up to <140/90 mmHg unless criteria met for 130/80 (see below)
    2. ADA Blood Pressure goals have been raised to <140/90
      1. Systolic Blood Pressure (SBP) <140 mmHg rationale (compared with intensive group <120 mmHg)
        1. Increased adverse effects (e.g. Hypotension, Hypokalemia) with intensive SBP lowering
        2. Cardiovascular events were NOT reduced with intensive SBP lowering
        3. Exception: CVA risk was reduced with intensive SBP lowering
          1. Number Needed to Treat: 89 for 5 years to prevent one CVA
      2. Diastolic Blood Pressure (DBP) <80 mmHg rationale
        1. Improved cardiovascular outcomes compared with DBP cutoff of 90
        2. However ADA returned to goal of <90 diastolic as of 2017
    3. Summary of goal Blood Pressures in Diabetes Mellitus
      1. Indications for BP <130/80 (per ADA), whereas this is the goal for all patients per ACC/AHA
        1. Diabetic Nephropathy
        2. Increased Cerebrovascular Accident Risk
          1. See Cerebrovascular Accident Risk Factors
        3. Younger patients with Diabetes Mellitus
          1. Longer exposure to pressure burden
          2. Better tolerate lower Blood Pressure
        4. Diabetes Mellitus and meeting BP <130/80 goals without adverse effects
      2. Indications for BP <140/90 (per ADA) or <130/80 (per ACC/AHA)
        1. Diabetes Mellitus without other indications
    4. Negotiate Blood Pressure goals with patient
      1. Balance potential benefits (cardiovascular event, Renal Function) with risks (e.g. Hypotension, Hypokalemia)
    5. References
      1. (2018) Presc Lett 25(5):26-7
      2. (2013) Diabetes Care January 36(suppl 1): S11-S66
        1. http://care.diabetesjournals.org/content/36/Supplement_1/S11.full.pdf
  4. Child: Average <95th percentile based on height, gender and age
    1. See Pediatric Hypertension
    2. See Hypertension Criteria
    3. NIH Information on Hypertension in Children
      1. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf

III. Complications: Hypertension adverse effects in Diabetes Mellitus

  1. Microvascular Complications
    1. Renal Insufficiency (and Proteinuria)
      1. ACE Inhibitors beneficial (except renal stenosis)
      2. Calcium Channel Blockers beneficial
      3. Angiotensin Receptor Blockers beneficial
    2. Autonomic Neuropathy (e.g. Impotence)
    3. Diabetic Retinopathy
  2. Macrovascular Complications
    1. Coronary Artery Disease
      1. ACE Inhibitors beneficial
      2. Thiazide Diuretics beneficial
      3. Long-acting Calcium Channel Blockers beneficial
        1. Nondihydropyridines (e.g. Verapamil) clearly are beneficial
        2. Mixed data on Dihydropyridines
      4. Beta Blockers beneficial
    2. Cerebrovascular Disease
      1. ACE Inhibitors beneficial
      2. Thiazide Diuretics beneficial
    3. Peripheral Vascular Disease

IV. Management: Medications

  1. First-Line Agents
    1. ACE Inhibitor
      1. Increases Glomerular Filtration Rate (GFR)
      2. Decreases Proteinuria
    2. Angiotension II Receptor Blockers
      1. Alternative to ACE Inhibitors
  2. Second-Line Agents
    1. Diuretics (especially in Isolated Systolic Hypertension)
  3. Third-Line Agents
    1. Beta Blockers
      1. Now thought to be a viable option for Hypertension control in Diabetes Mellitus
      2. Historically has been used only when other options have been exhausted
        1. Blunts hypoglycemic response (not seen in studies)
        2. Associated with increased weight gain
        3. Glucose and lipids less affected with Carvedilol
    2. Calcium Channel Blockers
      1. Non-Dihydropyridine Calcium Channel Blockers
      2. Dihydropyridine Calcium Channel Blockers
  4. Other Medications
    1. Alpha Antagonists (use only as adjunctive agent)

V. Management: Algorithm

  1. General
    1. See Hypertension Management
    2. See Nonpharmacologic Management of Hypertension
    3. See DASH Diet
  2. Protocol
    1. Start with 2 medications if goal is >20 mmHg lower than current Blood Pressure
    2. Anticipate needing as many as 3-4 Antihypertensives to reach goal
    3. Adjust in specific populations (e.g. Black)
      1. See Antihypertensives for Specific Populations
      2. May require ACE Inhibitor for renal protection, but other agents for Blood Pressure control
  3. Step 1: Start with ACE Inhibitor or Angiotensin Receptor Blocker (ARB)
    1. Proteinuria present
      1. Evidence supports ACE/ARB as first line
    2. Proteinuria absent
      1. No evidence for one Antihypertensive class over another
  4. Step 2: Add Diuretic
    1. Serum Creatinine >1.8: Loop Diuretic (e.g. Furosemide)
    2. Serum Creatinine <1.8: Thiazide Diuretic
      1. Hydrochlorothiazide
      2. Chlorthalidone (may be preferred)
        1. Longer Half-Life (better 24 hour control)
        2. Approaches twice the potency of Hydrochlorothiazide
        3. Higher risk of Hypokalemia
  5. Step 3: Add long-acting Calcium Channel Blocker
    1. Dihydropyridine Calcium Channel Blocker (e.g. Norvasc, Nifedipine) or
    2. Non-Dihydropyridine Calcium Channel Blocker (e.g. Verapamil, Diltiazem) or
      1. Do not use with Beta Blocker
  6. Step 4: Add Beta Blocker
    1. Use caution if Heart Rate <70-80 bpm
    2. Avoid if on Non-Dihydropyridine Calcium Channel Blocker (e.g. Verapamil, Diltiazem)
  7. Step 5: Add additional Antihypertensive (avoid these agents in the elderly, see Beers List)
    1. Central Adrenergic Agonist (e.g. Clonidine)
    2. Alpha Adrenergic Antagonist (e.g. Hytrin)
    3. Reserpine (very effective per JNC7, but review Drug Interactions)

VI. References

  1. (2003) Diabetes Care 26:S80-2 [PubMed]
  2. Arauz-Pacheco (2004) Diabetes Care 27:S65-7 [PubMed]
  3. Fineberg (1999) Prim Care 26:951-64 [PubMed]
  4. Konzem (2002) Am Fam Physician 66(7):1209-14 [PubMed]
  5. Whalen (2008) Am Fam Physician 78(11): 1277-82 [PubMed]

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Related Studies

Ontology: Hypertensive disease (C0020538)

Definition (MEDLINEPLUS)

Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps out blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is the diastolic pressure.

Your blood pressure reading uses these two numbers, the systolic and diastolic pressures. Usually they are written one above or before the other. A reading of

  • 119/79 or lower is normal blood pressure
  • 140/90 or higher is high blood pressure
  • Between 120 and 139 for the top number, or between 80 and 89 for the bottom number is prehypertension

High blood pressure usually has no symptoms, but it can cause serious problems such as stroke, heart failure, heart attack and kidney failure. You can control high blood pressure through healthy lifestyle habits and taking medicines, if needed.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI_CDISC) Pathological increase in blood pressure defined as one of the following: History of hypertension diagnosed and treated with medication, diet, and/or exercise; On at least 2 separate occasions, documented blood pressure greater than 140 mm Hg systolic and/or 90 mm Hg diastolic in patients without diabetes or chronic kidney disease, or blood pressure greater than 130 mm Hg systolic or 80 mm Hg diastolic in patients with diabetes or chronic kidney disease; Currently on pharmacological therapy for the treatment of hypertension.
Definition (NCI) Blood pressure that is abnormally high.
Definition (NCI_CTCAE) A disorder characterized by a pathological increase in blood pressure; a repeatedly elevation in the blood pressure exceeding 140 over 90 mm Hg.
Definition (NCI_NCI-GLOSS) A blood pressure of 140/90 or higher. High blood pressure usually has no symptoms. It can harm the arteries and cause an increase in the risk of stroke, heart attack, kidney failure, and blindness.
Definition (CSP) persistantly high arterial blood pressure.
Definition (MSH) Persistently high systemic arterial BLOOD PRESSURE. Based on multiple readings (BLOOD PRESSURE DETERMINATION), hypertension is currently defined as when SYSTOLIC PRESSURE is consistently greater than 140 mm Hg or when DIASTOLIC PRESSURE is consistently 90 mm Hg or more.
Concepts Disease or Syndrome (T047)
MSH D006973
ICD9 997.91, 401-405.99
ICD10 I10-I15.9 , I10, I10-I15
SnomedCT 38341003, 155302005, 194757006, 194760004, 155295004, 194756002, 266287006, 194794002, 195537001
LNC MTHU020789, LA14293-7, LA7444-8
English Hypertension, BLOOD PRESSURE HIGH, HYPERTENSION ARTERIAL, Hypertensive disease NOS, Hypertensive diseases, [X]Hypertensive diseases, Systemic hypertension, Hypertensive disorder, systemic arterial, hyperpiesia, hyperpiesis, systemic HTN, systemic hypertension (diagnosis), systemic hypertension, Hypertension arterial, Blood pressure high, HBP, HT, Hypertension NOS, Surg comp - hypertension, HTN, Hypertension [Disease/Finding], high blood pressure, hypertensive disorder, hypertensive vascular disease, arterial hypertension, arterial hypertension systemic, vascular hypertension, blood high pressure, high blood pressure disorder, systemic arterial hypertension, hypertensive disease, Hypertensive diseases (I10-I15), Complications affecting other specified body systems, not elsewhere classified, hypertension, High Blood Pressure, Hypertensive disease NOS (disorder), Hypertensive disease (disorder), (Hypertensive disease) or (hypertension), (Hypertensive disease) or (hypertension) (disorder), [X]Hypertensive diseases (disorder), hypertension, BLOOD PRESSURE, INCREASED, BLOOD PRESSURE, HIGH, Hypertensive Disorder, HIGH BLOOD PRESSURE, INCREASED BLOOD PRESSURE, HYPERTENSION, PRESSURE, HIGH BLOOD, High blood pressure, Hyperpiesia, Hyperpiesis, Hypertensive vascular degeneration, Hypertensive vascular disease, BP - High blood pressure, High blood pressure disorder, Systemic arterial hypertension, HBP - High blood pressure, BP+ - Hypertension, HT - Hypertension, Hypertensive disorder, systemic arterial (disorder), Hypertensive disorder, HTN - Hypertension, blood pressure; high, high; arterial tension, high; blood pressure, Hypertension, NOS, Hypertensive disease, NOS, Raised blood pressure (disorder), Blood Pressure, High, Blood Pressures, High, High Blood Pressures, Vascular Hypertensive Disorder, Hypertensive disease, HYPERTENSIVE DISEASE
French HYPERTENSION ARTERIELLE, Pression artérielle élevée, PAH, Hypertension SAI, TH, HYPERTENSION, TENSION ARTERIELLE E, Hypertension chronique, Hypertension permanente, Hypertension artérielle, Hypertension
Portuguese HIPERTENSAO, Hipertensão arterial NE, Hipertensão arterial, Pressão arterial alta, HYPERTENSAO ARTERIAL, PRESSAO SANGUINEA ELEVADA, Pressão Arterial Alta, Pressão Sanguínea Alta, Hipertensão
Spanish HIPERTENSION, PRESION SANGUINEA ALTA, Presión sanguínea alta, HTA, Hipertensión NEOM, Hipertensión arterial, HT, HIPERTENSION ARTERIAL, enfermedad hipertensiva, SAI, [X]enfermedades hipertensivas (trastorno), enfermedad hipertensiva, SAI (trastorno), [X]enfermedades hipertensivas, Hypertensive disease NOS, degeneración vascular hipertensiva, enfermedad hipertensiva, enfermedad vascular hipertensiva, hiperpiesia, hiperpiesis, hipertensión arterial (trastorno), hipertensión arterial, presión arterial alta, tensión arterial alta, tensión arterial elevada, Hipertensión, Presión Sanguínea Alta
German HYPERTONIE, Hypertonie, arteriell, Blutdruck, hoch, HBP, HT, Hypertonie NNB, BLUTDRUCK HOCH, HYPERTONIE ARTERIELL, Hypertension, Hypertonie
Dutch hypertensie NAO, hoge bloeddruk, arteriële hypertensie, bloeddruk; hoog, hoog; arteriële druk, hoog; bloeddruk, hypertensie, Bloeddruk, hoge, Hypertensie
Italian Ipertensione (HT), Ipertensione NAS, Pressione del sangue elevata, Ipertensione, Pressione sanguigna alta, Ipertensione arteriosa
Japanese 動脈性高血圧, 高血圧ＮＯＳ, ｺｳｹﾂｱﾂ, ｺｳｹﾂｱﾂNOS, ﾄﾞｳﾐｬｸｾｲｺｳｹﾂｱﾂ, 高血圧, 高血圧症
Swedish Högt blodtryck
Czech hypertenze, Arteriální hypertenze, Vysoký krevní tlak, Hypertenze NOS, Hypertenze, vysoký krevní tlak, hypertonie
Finnish Kohonnut verenpaine
Russian GIPERTENZIIA, GIPERTONICHESKAIA BOLEZN', KROVIANOE DAVLENIE VYSOKOE, ГИПЕРТЕНЗИЯ, ГИПЕРТОНИЧЕСКАЯ БОЛЕЗНЬ, КРОВЯНОЕ ДАВЛЕНИЕ ВЫСОКОЕ
Croatian HIPERTENZIJA
Polish Nadciśnienie
Hungarian Arteriás hypertonia, Hypertensio, HT, RR magas, Hypertonia k.m.n., Magas vérnyomás
Norwegian Høyt blodtrykk, Hypertensjon, Hypertoni
Derived from the NIH UMLS (Unified Medical Language System)

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