Diabetes Health Talk

Updated guidance published in the current issue of the American Society of Hypertension’s (ASH) Journal of Clinical Hypertension addresses the urgent need for physicians to take a more integrated, individualized approach to treating hypertension (high blood pressure) in patients with diabetes by treating the intricacies of each patient profile, rather than focusing on the disease in isolation. Early initiation of medications that block the renin angiotension system (ACE inhibitors or ARBs) coupled with either thiazide-like diuretics or calcium antagonists are needed to maintain BP <130/80 mmHg. Additionally, more frequent patient follow-up is recommended.

While the fundamentals of treatment and blood pressure goals remain unchanged, the authors emphasize that early detection of risk factors unique to each patient and earlier, more aggressive treatment be implemented. Follow-up visits after each medication adjustment should occur within 2-3 weeks as opposed to 4-8 weeks, and immediate referral to an ASH-certified clinical hypertension specialist should occur if repeated attempts to achieve blood pressure goal fails. Achieving and sustaining blood pressure goal earlier during treatment has been shown
retrospectively in many clinical trials to have an impact on stroke risk. Thus, such an approach is necessary to stop the cardiovascular event rates and stroke death toll from spiraling even further out of control.

Hypertension affects more than 70 million Americans and is the most prevalent risk factor for cardiovascular and kidney disease. More than 75% of adults with diabetes have hypertension or are using antihypertensive medications. If implemented, this new guidance will potentially lead to better control of blood pressure, blood sugar and blood fats, all major risk factors for cardiovascular events if they are not properly managed.

“We know that mortality increases by more than 7-fold when hypertension is present in patients with diabetes,” said George Bakris, MD, president-elect of the American Society of Hypertension, co-author of the Position Paper and professor, University of Chicago School of Medicine. “Because of their increased cardiovascular risk, these patients require an integrated therapeutic intervention that, in addition to blood pressure control, should include glycemic and lipid control and antiplatelet therapy. It is imperative that we attack all risk factors simultaneously and manage the profile of each patient type more vigilantly.”

The guidance from the American Society of Hypertension is offered in a series of recommendations, accompanied by a modified treatment algorithm. Of note, the guidance draws attention to the fact that treatment of blood pressure in people with diabetes must also focus on reducing proteinuria if present. Proteinuria refers to an excessive amount of protein in the urine and may be a sign of impending kidney failure and/or a precursor to stroke and other potentially life-threatening cardiovascular events. The guidance emphasizes the importance of early identification and management of proteinuria as part of its more integrative approach to patient management.