Managing hypertension in diabetes: a position statement from the ADA

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The ADA has released a position statement to update the assessment and treatment of hypertension among patients with diabetes.
The ADA has released a position statement to update the assessment and treatment of hypertension among patients with diabetes.

The American Diabetes Association (ADA) has released a position statement to update the assessment and treatment of hypertension among patients with diabetes.

The position statement, published in Diabetes Care, includes advances in care since the ADA last published a statement on this topic in 2003. The ADA notes that antihypertensive therapy is shown to reduce atherosclerotic cardiovascular disease (ASCVD) events, heart failure, and microvascular complications in patients with diabetes. There have also been reductions in ASCVD morbidity and mortality in patients with diabetes since 1990, which are likely due to improvements in blood pressure control.

“Treatment should be individualized to the specific patient based on their comorbidities; their anticipated benefit for reduction in ASCVD, heart failure, progressive diabetic kidney disease, and retinopathy events; and their risk of adverse events,” according to the ADA. “This conversation should be part of a shared decision-making process between the clinician and the individual patient.”

The ADA has made the following recommendations:

Screening and diagnosis

  • Clinicians should measure blood pressure at every routine clinical care visit. Patients with elevated blood pressure ≥140/90 mmHg should have blood pressure confirmed with multiple readings to diagnose hypertension (Grade B recommendation).
  • Hypertensive patients with diabetes should have home blood pressure monitoring to identify white-coat hypertension (Grade B recommendation).
  • Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed (Grade E recommendation).

Blood pressure targets

  • The systolic blood pressure goal should be <140 mmHg, and the diastolic blood pressure goal should be <90 mmHg for most individuals with diabetes and hypertension (Grade A recommendation).
  • Lower systolic and diastolic blood pressure targets may be appropriate for those with high risk of cardiovascular disease if they can be achieved without excessive treatment burden (Grade B recommendation).

Lifestyle management

  • Lifestyle intervention for those with systolic blood pressure >120 mmHg or diastolic blood pressure >80 mmHg consists of weight loss if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity (Grade B recommendation).

Pharmacologic antihypertensive treatment

  • Patients with confirmed blood pressure ≥140/90 mmHg should have timely titration of pharmacologic therapy to achieve blood pressure goals, in addition to lifestyle therapy (Grade A recommendation).
  • Patients with confirmed blood pressure ≥160/100 mmHg should have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes, in addition to lifestyle therapy (Grade A recommendation).
  • Treatment should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes. These include ACE inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (Grade A recommendation).
  • An ACE inhibitor or ARB is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to creatinine ratio  ≥ 300 mg/g creatinine (Grade A recommendation) or 30–299 mg/g creatinine (Grade B recommendation). If one class is not tolerated, the other should be substituted. (Grade B recommendation).
  • Serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored in patients treated with an ACE inhibitor, ARB, or diuretic (Grade B recommendation).

Blood pressure monitoring

  • Home blood pressure should be measured in patients receiving pharmacologic antihypertensive treatment to promote patient engagement in treatment and adherence (Grade B recommendation).

Resistant hypertension

  • Patients with resistant hypertension who are not meeting blood pressure targets on conventional drug therapy with 3 agents should be referred to a certified hypertension specialist (Grade E recommendation).
  • Patients with resistant hypertension who are not meeting blood pressure targets on conventional drug therapy with 3 agents should be considered for mineralocorticoid receptor antagonist therapy (Grade B recommendation).

Pregnancy

  • Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure <160 mmHg, diastolic blood pressure <105 mmHg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy (Grade E recommendation).
  • Systolic or diastolic blood pressure targets of 120–160/80–105 mmHg are suggested in pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy to optimize long-term maternal health and fetal growth (Grade E recommendation).

Reference

de Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care. 2017;40:1273-1284. doi:10.2337/dci17-0026

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