Hypertension is recognized as a significant metabolic factor contributing to the cardiovascular complications of diabetes, and there is a considerable evidence associating blood pressure (BP) reduction to a goal of less than 140/90 mmHg and improved clinical outcomes in most adult patients. For some patients with diabetes, lower BP targets should be considered on an individual basis when the benefit of tighter control exceeds the potential risk. Since some of these risks may result from the adverse effects of the prescribed BP medications, patients should be encouraged to discuss side-effect experiences with healthcare providers as part of the shared decision-making process.
With the introduction of new medication options and an additional decade of outcome data, the American Diabetes Association (ADA) released a position statement on the diagnosis and screening of hypertension, superseding the statement that was released almost 15 years ago. “In the past two decades, we have seen a decrease in ASCVD morbidity and mortality in people with diabetes, and evidence indicates that advances in blood pressure control are likely the key to such improvements,” said the Association’s Chief Scientific, Medical & Mission Officer William T. Cefalu, MD, in the ADA press release from August 22, 2017.
Uncontrolled hypertension is a significant, but modifiable, risk factor for cardiovascular complications of diabetes. The detailed recommendations, developed by the nine leading diabetes experts assigned to review and update the guidelines included in the ADA position paper, were published in August 2017. The position paper supports key messages for targeted treatment goals based on trials such as ACCORD, ADVANCE, and SPRINT, as well as new information that strongly supports considering the adoption of these targeted goals into clinical practice.
Given the limited time and resources available to primary care providers, it is important to remember the significance of incorporating a routine BP measurement at every clinic visit to improve health outcomes for patients. Also, providers should include orthostatic measurements of blood pressure to detect potential neuropathy that may result from uncontrolled diabetes. The ADA also recommends encouraging patients with diabetes who are also diagnosed with hypertension to take BP measurements at home to rule out “white coat” reactions that falsely inflate readings in the provider’s office.
Other clinical concerns included in the update reemphasizes prioritizing medication management based on BP measurement (i.e., when to start with two medications and how to treat to promote kidney health); promoting nonpharmacologic interventions such as healthy eating (i.e., DASH diet) and exercise; and focusing on specific treatment strategies for hypertension in older adults with diabetes.