ADA issues updated position statement on hypertension and diabetes

The American Diabetes Association (ADA) recently issued an updated position statement on diagnosis and treatment of hypertension in patients with diabetes.

The position statement, which updates the ADA's 2003 position statement on this topic, will appear in the September Diabetes Care and was published online on Aug. 22. It was developed by nine diabetes experts and summarizes clinical trials of intensive hypertension treatment strategies, such as the ACCORD BP (Action to Control Cardiovascular Risk in Diabetes-Blood Pressure) trial, the ADVANCEBP (Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation–Blood Pressure) trial, the HOT (Hypertension Optimal Treatment) trial, and SPRINT (Systolic Blood Pressure Intervention Trial).

The resulting recommendations include the following:

• Blood pressure should be measured at every routine clinical care visit in people with diabetes. If blood pressure is found to be 140/90 mm Hg or higher, it should be confirmed with multiple readings, including on a different day (B recommendation).
• All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension (B recommendation).
• The treatment goal for most patients with diabetes and hypertension should be below 140 mm Hg systolic and below 90 mm Hg diastolic (A recommendation).
• For patients at high risk for cardiovascular disease, lower targets, such as below 130/80 mm Hg, may be appropriate if they are achievable without undue treatment burden (B recommendation).
• For patients whose systolic blood pressure is above 120 mm Hg or diastolic blood pressure is above 80 mm Hg, lifestyle intervention should involve weight loss in those who are overweight or obese, the DASH (Dietary Approaches to Stop Hypertension) diet, increased fruit and vegetable intake and physical activity, and moderate alcohol intake (B recommendation).
• Patients whose blood pressure in the office is confirmed to be 140/90 mm Hg or greater should have timely titration of pharmacologic therapy to meet blood pressure goals, in addition to lifestyle therapy (A recommendation).
• Patients whose blood pressure in the office is confirmed to be 160/100 mm Hg or greater should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination shown to reduce cardiovascular events in diabetes (A recommendation).
• Hypertension treatment should include angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), thiazide-like diuretics, or dihydropyridine calcium-channel blockers. The recommendation notes that multiple-drug therapy is usually needed to reach blood pressure targets, but not a combination of ACE inhibitors and ARBs (A recommendation).
• An ACE inhibitor or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to-creatinine ratio ≥300 mg/g (A recommendation) or 30-299 mg/g (B recommendation).
• For patients treated with an ACE inhibitor, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored (B recommendation).

The recommendations also cover resistant hypertension and antihypertensive treatment in the absence of hypertension, as well as management of pregnant women and adults 65 years of age and older. A detailed algorithm to help guide treatment is included. The position statement is available free of charge online.