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ADA updates position statement on hypertension in diabetes
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For most patients with diabetes and hypertension, a combination of in-clinic and home-based blood pressure monitoring, a BP target of less than 140/90 mm Hg, individualized antihypertensive treatment and lifestyle modification are key to reduce the risk for atherosclerotic cardiovascular disease, heart failure and microvascular complications, according to a new position statement released by the American Diabetes Association.
The statement, written by nine leading diabetes experts on behalf of the ADA, updates the latest advances in care since the association last published a statement on the topic in 2003. The update incorporates findings from recent, noteworthy BP trials, including ACCORD, ADVANCE, SPRINT and the Hypertension Optimal Treatment (HOT) trial, and includes a newly added pictorial algorithm for the treatment of confirmed hypertension in patients with diabetes.
“There are a number of new findings in this position paper,” George Bakris, MD, professor of medicine and director of the ASH Comprehensive Hypertension Center at University of Chicago Medicine and a co-author of the statement, told Endocrine Today. “There is a recommendation to check standing BP on initial visits among people with diabetes to assess both autonomic function as well as potential volume depletion. While there is a strong position for a BP of less than 140/90 mm Hg, there is a clear recommendation for a BP of less than 130/80 mm Hg once the patient understands they are at high CV risk.”
Subsequent analyses from a long-term follow-up of ACCORD (ACCORDIAN) and multiple meta-analyses in thousands of patients suggest that a BP of less than 140 mm Hg clearly shows a significant reduction in CVD events and a slowed progression of nephropathy, Bakris said.
“Those who achieve a BP of less than 130 mm Hg show a further, albeit smaller, reduction in CVD events, but not renal events,” he said.
Lifestyle management plans for lowering BP are also highlighted in the guideline and include suggestions on weight loss, nutrition and increased physical activity. The statement also details the recommended approach for the use of medication in the treatment of hypertension in people with diabetes, which depends on initial BP, kidney health, response to treatment and adverse effects.
Angiotensin-converting enzyme inhibitors or angiotensin receptor blocker therapy are not indicated — and should not be used — in adults who are normotensive or have microalbuminuria, regardless of a patient’s BP level, Bakris said. Renin-angiotensin system (RAS) inhibition is necessary in people with albumin excretion of at least 300 mg per day who have hypertension, he said, and there is a recommendation to avoid a diastolic BP less than 60 mm Hg.
“In those with hypertension and less than 300 mg albuminuria, initial therapy with either a RAS blocker, calcium channel blocker or a thiazide-like diuretic is indicated, and those who are at least 20/10 mm Hg above the BP goal should be given single-pill combinations of either RAS blockers/calcium channel blockers or RAS blockers/diuretics,” Bakris said.
The statement emphasizes that women with pre-existing hypertension or mild gestational hypertension (BP < 160/105 mm Hg) and no evidence of end-organ damage should not be treated with antihypertensive medications, as there is no benefit that clearly outweighs the potential risks, the authors noted. BP targets and potential medication guidelines are also included for pregnant patients with diabetes who do require treatment for hypertension.
The statement also noted that there is little evidence that BP medication improves health outcomes in patients with diabetes but without hypertension.
“In the past 2 decades, we have seen a decrease in [atherosclerotic] CVD morbidity and mortality in people with diabetes, and evidence indicates that advances in blood pressure control are likely the key to such improvements,” William T. Cefalu, MD, chief scientific, medical and mission officer for the ADA, said in a press release. “As medical and pharmacological developments occur, it is imperative that medical providers, diabetes educators and patients stay abreast of the most current care recommendations that can lead to improved cardiovascular health for people with diabetes and will ultimately result in better overall health and fewer diabetes-related complications.”
The position statement was published online in Diabetes Care. – by Regina Schaffer
Disclosures: de Boer reports consulting for Boehringer Ingelheim and Ironwood Pharmaceuticals and reports that his institution has received research equipment and supplies from Abbott and Medtronic. Please see the full position statement for the other authors’ relevant financial disclosures.
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