Part Two: Managing Hypertension in Patients with T2DM (The “B” of ABCS)

As noted earlier, hypertension is a common comorbidity of T2DM, and its presence doubles the risk of CVD in persons with T2DM.77 Numerous professional organizations, including the American Diabetes Association,17 the American Heart Association/American College of Cardiology/American Society of Hypertension,78 and the National Heart, Lung, and Blood Institute,79 have issued recommendations to manage hypertension in the context of other risk factors. These recommendations generally advocate for a target of 140-150 mmHg systolic and of 90 mmHg diastolic pressure, values that have been associated with reduction of CHD events, stroke, and diabetic kidney disease in individuals with diabetes.17 The added value of treating to a more aggressive target (e.g., < 130 mmHg systolic and < 80 mmHg diastolic pressures), however, has not been fully established. Intensive treatment is not associated with significant reductions in mortality or risk of myocardial infarction in patients with T2DM, although a small reduction in the risk of stroke has been observed.80 Moreover, intensive blood pressure management may cause hypotension or syncope. While intensive treatment may be appropriate for select patients, authors of a recent Cochrane Review of six randomized trials (n=9,795; mean follow-up 3.7 years) concluded that evidence does not support blood pressure targets lower than the standard targets in people with elevated blood pressure and a history of CVD.81 To this end, the ADA recommends that most individuals with diabetes and hypertension be treated to a target of less than 140/90 mm Hg (Evidence Category: A) but notes that lower systolic and diastolic blood pressure targets, such as 130/80 mm Hg, may be appropriate for individuals at high risk for CVD, if the target can be achieved without undue treatment burden (Evidence Category: C).17 The AHA guidelines also note that 130/80 mm Hg may be an appropriate target in some individuals with coronary artery disease, previous myocardial infarction, stroke/transient ischemic attack, or coronary artery disease risk equivalents (e.g., carotid artery disease, peripheral arterial disease, or abdominal aortic aneurysm).78 The ADA recommends that blood pressure be measured at all routine visits, and evidence of elevated blood pressure should be confirmed on a separate day (Evidence Rating: B).17 The ADA also recommends that all hypertensive patients with diabetes monitor their blood pressure at home (Evidence Rating: B).17 Figure 3 shows the ADA algorithm for treating patients with diabetes who have confirmed hypertension.17


















Figure 3. ADA recommendations for treating confirmed hypertension in people with diabetes.17 *An ACE inhibitor (ACEi) or angiotensin II receptor blocker (ARB) is suggested to treat hypertension for patients with a urine-to-albumin creatinine ratio (UACR) 30–299 mg/g creatinine and strongly recommended for patients with UACR > 300 mg/g creatinine. **Thiazide-like diuretic; long-acting agents shown to reduce cardiovascular events, such as chlorthalidone and indapamide, are preferred.

***Dihydropyridine calcium channel blocker (CCB). BP, blood pressure.

Table 6 lists the ADA’s 2018 recommendations for treating hypertension in patients with diabetes. It should be noted that many patients with diabetes and hypertension will require multiple-drug therapy to achieve blood pressure targets. The ADA notes, however, that blood pressure that remains uncontrolled despite confirmed adherence to optimal doses of three or more antihypertensive agents from different classes (one of which should be a diuretic) should prompt the physician/clinician to evaluate secondary causes of hypertension.17

Table 6. ADA Recommendations for Treating Hypertension17


Level of Evidence*

For patients with blood pressure > 120/80 mmHg, lifestyle intervention consists of weight loss if overweight or obese, a Dietary Approaches to Stop Hypertension-style dietary 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, or dihydropyridine calcium channel blockers). While multiple-drug therapy is generally required to achieve blood pressure targets, combinations of ACE inhibitors and angiotensin receptor blockers with or without direct renin inhibitors should not be used.


An ACE inhibitor or angiotensin receptor blocker, 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 (1) or 30–299 mg/g creatinine (2). If one class is not tolerated, the other should be substituted (3).

Statement 1: A

Statement 2: B

Statement 3: B

For patients treated with an ACE inhibitor, angiotensin receptor blocker, or diuretic, serum creatinine/eGFR and serum potassium levels should be monitored at least annually.


Patients with hypertension who are not meeting blood pressure targets on three classes of antihypertensive medications (including a diuretic) should be considered for mineralocorticoid receptor antagonist therapy.


*The ADA evidence grading system for these recommendations is provided in Table 2.47

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