Canadian Diabetes Association Clinical Practice Guidelines Treatment of Hypertension Chapter 25...

Canadian Diabetes Association Clinical Practice Guidelines

Treatment of Hypertension

Chapter 25

Richard E. Gilbert, Doreen Rabi, Pierre LaRochelle, Lawrence A. Leiter, Charlotte Jones, Richard Ogilvie, Sheldon Tobe, Nadia Khan, Luc Poirier, Vincent Woo

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright © 2013 Canadian Diabetes Association

ASSESS for hypertension (≥130/80 mmHg)

TREAT to target <130/80 mmHg

USE multiple antihypertensive medications if needed

to achieve target (often necessary)

USE initial combination therapy if systolic blood

pressure >20 mmHg above target or diastolic blood

pressure >10 mmHg above target

2013Hypertension Checklist


BP >130/80 mm Hg

Confirmed on a second occasion in either the office,

home or by appropriate ambulatory measurement.

Making the Diagnosis of Hypertension in Patients with Diabetes

UKPDS Study Group. BMJ 1998; 317:703-13.

50

40

30

20

10

0

Years from randomization

Pat

ient

s w

ith e

vent

s (%

)

0 1 2 3 4 5 6 7 8 9

Less tight control (mean BP 154/87 mmHg)

Tight control (mean BP 144/82 mmHg)

Tight BP control:24% reduction of events(95% CI 8-38)

Tight BP control:24% reduction of events(95% CI 8-38)

Hypertension in Diabetes (UKPDS)



Arch Intern Med 2005;165:1410-1419

Benefits of BP Lowering in DM

• Meta-analysis of 27 randomized trials showed

intense BP reduction (i.e., by 6/4.6 mmHg)

resulted in:– 36% reduction in stroke

– 27% reduction in total mortality

– 25% reduction in major cardiovascular events

Hansson et al. Lancet. 1998;351:1755.

P<0.005

MI,

str

oke,

CV

m

orta

lity/

1000

pt-

yDiabetes Subgroup

90 mm Hg (n=501) 85 mm Hg (n=501) 80 mm Hg (n=499)

Goal of therapy: target diastolic BP

24.4

18.8

11.9

30

25

20

15

10

5

0

Hansson et al. Lancet. 1998;351:1755.

HOT: BP Control Reduces CV Events



<130/80 mmHg

Multiple anti-hypertensive agents may be needed to achieve the desired target

Target Blood Pressure


Threshold equal or over 130/80 mmHg and target below 130/80 mmHg

With Nephropathy* or CVD or CV

risk factors

*Urinary albumin to creatinine ratio >2.0 mg/mmol

Diabetes

WithoutThe above

Isolated Systolic Hypertension

Systolic-diastolicHypertension

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic

above target

Combinations of an ACEI with an ARB are specifically not

recommended in the absence of proteinuria

Pharmacotherapy for Hypertension in Patients with Diabetes

*Based on at least 2 of 3 measurementsCVD = Cardiovascular Disease; CV = Cardiovascular


THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min (0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

DIABETESwith

Nephropathy or CVD or

CV risk factors

ACE Inhibitoror ARB

IF ACEI and ARB are contraindicated or not tolerated, SUBSTITUTE• Long-acting CCB or• Thiazide diuretic

Addition of a Dihydropyridine CCB is preferable to HCTZ

3 - 4 drugs in combination may be needed

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

CCB = Calcium Channel Blocker; HCTZ = Hydrochlorothiazide; CKD = Chronic Kidney Disease

Pharmacotherapy of Hypertension with Nephropathy, CVD or CV Risk Factors


THRESHOLD equal or over 130/80 mmHg and TARGET below 130/80 mmHg

DIABETESwithout

Nephropathy, CVD or CV risk factors

1. ACE Inhibitor or ARB or

2. Dihydropyridine CCB or Thiazide diuretic

IF ACE Inhibitor, ARB, DHP-CCB and Thiazide are contraindicated or not tolerated,

SUBSTITUTE– Cardioselective BB* or– Long-acting NON DHP-CCB

Combination of first line agents

Addition of one or more of:Cardioselective BB or Long-acting CCB

Combinations of an ACE Inhibitor with an ARB are specifically not recommended in the absence of proteinuria

Pharmacotherapy of Hypertension in Diabetes without Nephropathy, CVD or CV Risk Factors

*Cardioselective BB: Acebutolol, Atenolol, Bisoprolol , Metoprolol


Threshold equal or over 130/80 mmHg and Target below 130/80 mmHg

With Nephropathy, CVD or CV risk factors

ACE Inhibitor or ARB

Diabetes

Withoutthe above

1. ACE Inhibitor or ARB or

2. Thiazide diureticor DHP-CCB

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuriaMore than 3 drugs may be needed to reach target values

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic should be substituted for a thiazide diuretic if control of volume is desired

Combination of 2 first line drugs may be considered

as initial therapy if the blood pressure is

>20 mmHg systolic or >10 mmHg diastolic

above target

> 2-drug combinations

Summary of Pharmacotherapy for Hypertension in Patients with Diabetes


1. Persons with diabetes mellitus should be treated to

attain a *SBP of <130 mmHg [Grade C, Level 3] and a **DBP

of <80 mmHg [Grade A, Level 1]. (These target BP levels

are the same as the BP treatment thresholds).

Combination therapy using two first-line agents may

also be considered as initial treatment of hypertension

[Grade C, Level 3] if SBP is 20 mmHg above target or if

DBP is 10 mmHg above target. However, caution

should be exercised in patients in whom a substantial

fall in BP is more likely or poorly tolerated (e.g., elderly

patients and patients with autonomic neuropathy)

*SBP= Systolic Blood Pressure **DBP= Diastolic blood pressure

2013Recommendation 1


2. For persons with cardiovascular or kidney

disease, including microalbuminuria, or with

cardiovascular risk factors in addition to diabetes

and hypertension, an ACE inhibitor or an ARB is

recommended as initial therapy [Grade A, Level 1A]

3. For persons with DM and HTN not included in the

above recommendation, appropriate choices

include (in alphabetical order): ACE inhibitors [Grade A,

Level 1A], ARBs [Grade A, Level 1A], dihydropyridine CCBs

[Grade A, Level 1A], and thiazide/thiazide-like diuretics [Grade A, Level 1A].

Recommendations 2 and 3


4. If target BP levels are not achieved with standard-

dose monotherapy, additional antihypertensive

therapy should be used [Grade D, Consensus]. For

persons in whom combination therapy with an

ACE inhibitor is being considered, a

dihydropyridine CCB is preferable to

hydrochlorothiazide [Grade A, Level 1A]

2013Recommendation 4

CDA Clinical Practice Guidelines

www.guidelines.diabetes.ca – for professionals

1-800-BANTING (226-8464)

www.diabetes.ca – for patients

http://guidelines.diabetes.ca/

http://diabetes.ca/

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Canadian Diabetes Association Clinical Practice Guidelines Treatment of Hypertension Chapter 25...

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