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Diabetics: Treating High Blood Pressure

Controlling Blood Pressure Is Essential For Diabetics

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Updated May 01, 2014

Effective blood pressure control is an important goal for diabetic patients. The dangers of high blood pressure in diabetics are so serious that some studies have suggested that well-controlled blood pressure in diabetic patients makes a more powerful impact on long-term health (quality of life, number of complications, ultimate lifespan) than does tight blood sugar control. While that doesn’t mean you should ignore your blood sugar goals, it does reinforce the idea that controlling blood pressure is an essential goal.

Treatment Goals

In the setting of diabetes, the target blood pressure is <130/80. The topic of target blood pressures has been well-researched, and several large studies have consistently shown that significant improvements in long term cardiovascular and kidney health do not become apparent until blood pressure is reduced to this level. For this reason, doctors tend to be very aggressive when devising treatment plans for diabetic patients.

Some studies have suggested that certain groups of diabetic patients -- like those with preexisting kidney problems -- benefit most from blood pressures less than 120/80. Data has shown that the risk of cardiovascular problems and further kidney damage approach their lowest measurable values within this range. Because it is difficult to reduce blood pressure to this level, it is a recommendation usually reserved only for specific patients.

Non-Drug Therapy

The official guidelines of both the American Heart Association and the American Diabetes Association state that blood pressures in the range of 130-139/80-89 should first be treated with “non-pharmacologic” (no medicine) options. These options include:

In patients without diabetes, strict adherence to these rules very often leads to significant drops in blood pressure, enough so that drug therapy may not be needed. While the same can occur in diabetic patients, it is less common, and drug therapy is usually needed. These changes are still worthwhile, though, because they increase the effectiveness of the drug therapy and ultimately lead to better blood pressure control.

Drug Therapy

Drug therapy is a necessary step for most patients at some point during treatment. Vast amounts of research have been done in an effort to determine which drug or drug combination is the “best” for treating high blood pressure in patients with diabetes. Though study results vary slightly, there is a near universal consensus that the best drugs to use in the setting of diabetes are:

These drugs specifically address several concerns associated with high blood pressure in the setting of diabetes including volume expansion, blood vessel stiffness, and kidney damage. Though some doctors initially begin therapy by trying a diuretic on its own, it is more common to begin with an ACE Inhibitor. Ultimately, some ACE Inhibitor / ARB combination is usually the treatment of choice, with a diuretic added if needed. Though this is the most common type of drug treatment, other drugs may be included depending on specific patient factors.

If your doctor chooses to start therapy with a diuretic, be aware that this is not a bad choice, and there is evidence to support this decision in certain types of patients. It will be clear very quickly whether the treatment is working or not, and adjustments will be made if necessary.

Follow-Up Care

Whatever the specific treatment being administered, proper follow up care is essential to managing the long term success of your therapy. In the beginning, you’ll likely see your doctor monthly, or even bi-weekly, until an effective plan is in place. Then, many doctors will ask you to come back every three months for the first year. This close follow up is used to track changes in blood pressure and establish a baseline for certain physical parameters like electrolyte levels (potassium and sodium in the blood) and kidney function.

After the first year, your doctor may choose to switch to six month appointments, or might want you to continue on the three-month schedule. If you are asked to continue the three month schedule, this is not a cause for alarm, it just means that more time is needed to ensure that everything is going as planned. A growing number of doctors are asking all diabetic patients with high blood pressure to come in every three months. Keeping these appointments is important. Treatment is most effective when paired with a schedule of proper follow-up care.

Learn More:

Sources:

  1. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002; 288:2981.
  2. Buse, JB, Ginsberg, HN, Bakris, GL, et al. Primary prevention of cardiovascular diseases in people with diabetes mellitus: a scientific statement from the American Heart Association and the American Diabetes Association. Circulation 2007; 115:114.
  3. Gaede, P, Vedel, P, Parving, H-H, Pedersen, O. Intensified multifactorial intervention in patients with type 2 diabetes mellitus and microalbuminuria: The Steno type 2 randomised study. Lancet 1999; 353:617.
  4. Zillich, AJ, Garg, J, Basu, S, et al. Thiazide diuretics, potassium, and the development of diabetes: a quantitative review. Hypertension 2006; 48:219.
  5. Daly, CA, Fox, KM, Remme, WJ, et al. The effect of perindopril on cardiovascular morbidity and mortality in patients with diabetes in the EUROPA study: results from the PERSUADE substudy. Eur Heart J 2005; 26:1369.
  6. Brenner, BM, Cooper, ME, de Zeeuw, D, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001; 345:861.
  7. American Diabetes Association. Hypertension Management in Adults with diabetes. Diabetes Care 2004; 27(Suppl 1):S65.

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