Here is a concise summary of the 2020 ADA guidelines on the approach of hypertension in patients with diabetes. The authors discuss lifestyle, medications, drug side-effects, and blood pressure (BP) targets. Goals are to achieve BP <130/80, <135/85, and <140/90 mmHg in adults at high risk for ASCVD, gestational diabetes, and low-ASCVD risk, respectively.
Dr. Tashko
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ADA GUIDELINES, Hypertension
JANUARY 2020
- Blood pressure should be measured at every routine clinical visit. Patients found to have elevated blood pressure (≥140/90 mmHg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.
- All hypertensive patients with diabetes should monitor their blood pressure at home.
- For patients with diabetes and hypertension, blood pressure targets should be individualized through a shared decision-making process that addresses cardiovascular risk, potential adverse effects of antihypertensive medications, and patient preferences.
- For individuals with diabetes and hypertension and at HIGHER cardiovascular risk (existing atherosclerotic cardiovascular disease [ASCVD] or 10-year ASCVD risk ≥15%), a blood pressure target of <130/80 mmHg may be appropriate, if it can be safely attained.
- For individuals with diabetes and hypertension at LOWER risk for cardiovascular disease (10-year atherosclerotic cardiovascular disease risk <15%), treat to a blood pressure target of <140/90 mmHg.
- In pregnant patients with diabetes and pre-existing hypertension, a blood pressure target of ≤135/85 mmHg is suggested in the interest of reducing the risk for accelerated maternal hypertension and minimizing impaired fetal growth.
- For patients with blood pressure >120/80 mmHg, lifestyle intervention consists of
- Weight loss if overweight or obese,
- Dietary Approaches to Stop Hypertension (DASH)-style eating pattern including
- Reducing sodium and
- Increasing potassium intake
- Moderation of alcohol intake, and
- Increased physical activity.
- Patients with confirmed office-based blood pressure ≥140/90 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of pharmacologic therapy to achieve blood pressure goals.
- Patients with confirmed office-based blood pressure ≥160/100 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes.
- Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes:
- ACE inhibitors
- Angiotensin receptor blockers
- Thiazide-like diuretics
- Dihydropyridine calcium channel blockers.
- Multiple-drug therapy is generally required to achieve blood pressure targets.
- However, combinations of ACE inhibitors and angiotensin receptor blockers and combinations of ACE inhibitors or angiotensin receptor blockers with direct renin inhibitors should not be used.
- An ACEi or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urinary albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. If one class is not tolerated, the other should be substituted.
- For patients treated with an ACEi, ARB, or diuretic –serum eGFR and serum K++ levels should be monitored at least annually.
- Patients with hypertension who are not meeting blood pressure targets on 3 classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy.