Clinicians should consider adding a loop diuretic for patients with GFR rates <30 ml x min/1.73 m2. Commonly used loop diuretics in diabetic hypertension include furosemide, torsemide and bumetanide. If the serum creatinine level increases by more than 30 percent or hyperkalemia (elevated potassium levels) develops, these agents should be stopped or the dosages reduced.

Beta Blockers and Calcium Channel Blockers

Beta-blockers and calcium channel blockers (CCBs) can also be added as part of multidrug therapy in combination with ACE/ARB therapy and diuretics.


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Beta-blockers should be incorporated into the initial antihypertensive regimen in patients with diabetes who have a history of MI, HF, CAD or stable angina. Commonly prescribed beta-blockers include carvedilol, metoprolol and atenolol. Avoid prescribing labetalol and atenolol in insulin-dependent diabetic patients.4

Consider dihydropyridine CCBs, such as diltiazem, amlodipine, and nifedipine, as alternative for patients who cannot tolerate preferred therapies or who need additional therapy to achieve target BP levels. Results from the ACCOMPLISH trial indicated that combining the ACE inhibitor benazepril plus amlodipine reduced the number of CV events in patients with diabetes compared with those taking benazepril plus the diuretic hydrochlorothiazide.10

If hypertension is still not controlled alpha-blockers, including doxazosin or terazosin, may be tried. A direct renin inhibitor, aliskiren, is among the newest hypertension medications. Although its place in treating hypertension in people with diabetes is still in flux, data from the AVOID trial showed the drug’s renal protective effects are promises in patients at risk for kidney damage.11

Lifestyle interventions

Lifestyle interventions for patients with diabetes and hypertension include losing weight, making dietary changes, moderating alcohol, quitting smoking and exercising.

Reducing sodium to 2,300 mg per day and increasing potassium should be the main focus of dietary interventions. Recently, the Institutes of Medicine recommended cutting sodium intake even further, to 1,500 mg per day.13

Evidence exists that the DASH diet, a diet low in sodium, saturated fat, cholesterol and total fat and high in fruits and vegetables, is effective at lowering BP. Results from a study published in Diabetes Care in 2010 indicated that patients with type 2 diabetes WHO adopted a DASH diet reduced systolic BP by -13.6±3.5 mm Hg and diastolic BP by −9.5±2.6 mm Hg.14

In addition to dietary modifications, ADA practice guidelines recommend that people with diabetes get at least 150 minutes of moderate intensity aerobic physical activity a week. In the absence of contraindications, patients should be encouraged to perform resistance training three times per week. However, for patients with uncontrolled hypertension, exercise programs need to be moderated.

Alice McCarthy is a freelance medical writer.

References

1.     CDC. Morb Mortal Wkly Rep. 2011: 60(04);103-108.

2.     American Diabetes Association website: www.diabetes.org

3.     Alder AI et al. BMJ. 2000;321:412–419.

4.     Salanitro AH, Roumie CL. Clin Diabetes. 2010:28; 107-114.

5.     American Diabetes Association. Diabetes Care. 2010;34:S3.

6.     American Diabetes Association. Diabetes Care. 2004:27; s79-s83.

7.     National Kidney Foundation. Clinical Practice Guidelines on Hypertension and Antihypertensive Agents in Chronic Kidney Disease. http://www.kidney.org. Accessed March 10, 2011.

8.     Mann JF. Lancet. 2008;372: 547-53.

9.     Wong J. Diabetes, Obesity and Metabolism. 2010; 12:1072-1078.

10. Weber MA et al. J Am Coll Cardiol. 2010;56:77-85.

11. Parving HH et al. N Engl J Med. 2008;358:2433-2446.

12. American Diabetes Association. Diabetes Care. 2008;31:S61-S78.

13. National Institute of Health. DASH Diet. www.nhlbi.nih.gov. Accessed March 10, 2011.

14. Azadbakht L et al. Diabetes Care. 2010; doi:10.2337/dc10-0676.