Hypertension
Compelling and possible indications/contraindications
Background
Hypertension is a major cardiovascular risk factor which develops in the majority of people with diabetes. Hypertensive diabetic patients are also at increased risk of diabetes-specific complications including retinopathy and nephropathy. Both the UKPDS and the Hypertension Optimal Treatment (HOT) trial showed improved outcomes in patients assigned to lower blood pressure targets. The aims of treatment are:
- To reduce systolic blood pressure to < 140mmHg
- To reduce diastolic blood pressure to < 80mmHg
- To reduce blood pressure to < 130/80mmHg if diabetes and CHD co-exist or if microalbuminuria present
Recommended Action
Blood Pressure (mmHg) |
Recommended Action |
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<140/80 |
Reassess annually. |
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141-199 / 81-99 |
Confirm by 3 readings over 3-4 weeks, then initiate treatment. |
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200-219 / 110-119 |
Confirm by 3 readings over 1-2 weeks then treat (unless malignant phase or hypertensive emergency - admit immediately). |
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>220/120 |
Treat immediately. |
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If hypertension confirmed
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ECG
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Fasting lipid profile |
U&E |
Urine - blood/protein |
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Treatment
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See below |
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Follow up |
Review monthly x 3 months Then at 6 months Then annually Continue to advise on lifestyle measures |
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Specialist referral |
Malignant hypertension/ hypertensive emergency
Evaluation of therapeutic problems |
Investigation of underlying causes
Patients with resistant BP (>150/90 despite 3 or more agents)/ white coat hypertension/ pregnancy |
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Lifestyle Modification
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Advise all patients to institute lifestyle measures aimed at controlling hypertension
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Restrict alcohol - < 21units/week (men) or < 14 units/week (women)
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Reduce salt (but caution re potassium in salt alternatives) and saturated fat intake, increase fruit and vegetables . Consider weight loss if BMI> 25. Avoid effervescent/soluble tablets and certain indigestion products - high in salt content
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Recommend regular physical activity, stop smoking - consider motivation to quit, referral to smoking cessation service, NRT, bupropion
First line treatment
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Use ACE inhibitors as first line therapy in people with diabetes, especially if also have microalbuminuria or nephropathy. Treat blood pressure aggressively in people with diabetes. Multiple therapy often required
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Use angiotensin II antagonists as the first choice alternative if ACE inhibitors are not tolerated. Choice of other first line medication will depend on relative indications and contra-indications in the individual patient (see below)
Combination Treatment
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Two or more agents are generally required to achieve blood pressure targets. Useful combinations are:
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An ACE inhibitor or ARB combined with a thiazide or loop diuretic
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An ACE inhibitor combined with an ARB (but check for hyperkalaemia)
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A calcium antagonist or beta blocker or alpha blocker as a third agent
Compelling and possible indications/contraindications
Class of Drug |
Compelling Indications |
Possible Indications |
Possible Contraindications |
Compelling Contraindications |
Thiazides- Bendrofluazide 2.5mg |
Elderly patients (including ISH) |
|
Dyslipidaemia |
Gout |
Loop diuretics Furosemide |
Oedema Impaired renal function Heart failure |
Pregnancy Breast feeding Hypovolaemia |
Cirrhosis Anuria |
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Potassium sparing diuretics Spironolactone |
CCF Oedema in Cirrhosis Nephrotic syndrome |
Limit potassium loss with thiazide diuretics |
Impaired renal function |
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Beta-blockers - Atenolol
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Myocardial infarction Angina |
Heart failure *** (Bisoprolol) |
Heart failure *** Dyslipidaemia Peripheral Vascular Disease |
Asthma/COAD Heart block |
Calcium antagonists (Dihydropyridine) - Felodipine/ Adalat LA/ Amlodipine |
Elderly ISH |
Elderly Angina
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|
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ACE-inhibitors - Lisinopril RamiprilPerindopril Fosinopril |
Heart failure LV dysfunction Type 1 diabetic nephropathy |
Chronic renal disease * Type 2 diabetic nephropathy |
Renal impairment Peripheral Vascular Disease (PVD) ** Aortic stenosis |
Pregnancy Renovascular disease |
Calcium antagonists (rate-limiting) - Verapamil / Diltiazem |
Angina |
Myocardial Infarction |
Combination with beta blockade |
Heart block Heart failure |
Alpha-blockers - Doxazosin/ Prazosin |
Prostatism |
Dyslipidaemia |
Postural hypotension |
Urinary incontinence |
Angiotensin receptor blockers- (ARB's) Irbesartan Valsartan Losartan |
To be used where ACE inhibitors are indicated, but cannot be tolerated |
Heart failure Intolerance of other antihypertensive drugs |
PVD ** |
Pregnancy Renovascular disease |
* ACE inhibitors may be beneficial in chronic renal failure but should be used with caution. Close supervision and specialist advice is needed when there is established and significant renal impairment.
** Caution with ACE inhibitors and angiotensin 11 receptor antagonists in peripheral vascular disease because of association with renovascular disease.
*** Beta-blockers may worsen heart failure, but in specialist hands may be used to treat heart failure
Additional drug therapy
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Aspirin 75mg daily should be added once the BP has ben brought down to <150/90
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Lipid lowering therapy may also be required
Referral
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If BP>150 systolic or >90 diastolic despite 3 or more agents refer to the hospital diabetic clinic