Hypertension in Patients With Diabetes
Patients with diabetes can benefit from blood pressure control to reduce the risks of cardiovascular disease, retinopathy, and renal disease. The chart below provides information pertaining to common questions that arise when treating hypertension in these patients.
Abbreviations: ACC = American College of Cardiology; ADA = American Diabetes Association; AHA = American Heart Association; BP = blood pressure; CV = cardiovascular disease; DBP = diastolic blood pressure; eGFR = estimated glomerular filtration rate; ISH = International Society of Hypertension; LVH = left ventricular hypertrophy; MI = myocardial infarction SBP = systolic blood pressure
Pertinent Information or Resources
What is the goal blood pressure in patients with diabetes?
ACC/AHA: <130/80 mmHg1
ADA: <140/90 mmHg for most patients, but suggests <130/80 mmHg for select patients (e.g., patients at high risk of CV disease who are able to reach this goal without significant side effects).4
JNC 8: <140/90 mmHg2
ISH: <140/90 mmHg7
Hypertension Canada: <130/80 mmHg8
Diabetes Canada: <130/80 mmHg9
Why do different guidelines recommend different blood pressure targets?
Variance is due to differences in which studies the guideline authors include and the weight they place on evidence.
ACC/AHA vs ADA
Choose an agent shown to reduce CV events in patients with diabetes: ACEI, ARB, dihydropyridine CCB, or thiazide/thiazide-like diuretic (Hypertension Canada and Diabetes Canada give preference to chlorthalidone or indapamide due to evidence supporting CV benefit with these longer-acting diuretics9,15).1,2,4,7-9 (Note that neither JNC 8 nor ACC/AHA specify “dihydropyridine,” and ACC/AHA does not specify “thiazide.” ISH recommends ACEI or ARB first-line, except in black patients, in which a CCB or thiazide could be used first-line.7)
Hypertension Canada and Diabetes Canada recommend a dihydropyridine CCB as the preferred add-on to an ACEI or ARB.8,9
Some guidelines recommend specific agents for comorbidities in the context of diabetes:
Why doesn’t intensive blood pressure reduction show clear benefit in diabetes?
Lack of clear benefit may be a result of study limitations. For example, ACCORD (described above) had a low event rate, included patients who had low CV risk, may have been underpowered to detect a benefit, and used hydrochlorothiazide, a short-acting thiazide with less consistent evidence of CV benefit vs chlorthalidone (which was used in SPRINT, described above).13,14
Diabetes affects arteriolar function and blood flow as it relates to blood pressure, such that reducing blood pressure below a point that might be tolerated in a nondiabetic might significantly reduce blood flow to end organs in patients with diabetes.13
Diabetes may potentiate vascular damage such that vacular structure and function may not be amenable to the benefits of a lower SBP.17
How should treatment of hypertension in diabetes patients be individualized?
Should patients with diabetes be encouraged to check blood pressure at home?
The ADA recommends home blood pressure monitoring to identify white coat hypertension or masked hypertension (i.e., normal blood pressure in office; elevated blood pressure at home), and to promote adherence and interest.4
Hypertension Canada recommends home blood pressure monitoring in patients with diabetes.8
Project Leader in preparation of this clinical resource (340501): Melanie Cupp, Pharm.D., BCPS
- Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension 2017 Nov 13 [Epub ahead of print].
- James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311:507-20.
- ACCORD Study Group. Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575-85.
- De Boer IH, Bangalore S, Benetos A, et al. Diabetes and hypertension: a position statement by the American Diabetes Association. Diabetes Care 2017;40:1273-84.
- Patel A, MacMahon S, Chalmers J, et al. Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): a randomised controlled trial. Lancet 2007;370:829–840.
- SPRINT Research Group. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med 2015;373:2103-16.
- Weber MA, Schiffrin EL, White WB, et al. Clinical practice guidelines for the management of hypertension in the community: a statement by the American Society of Hypertension and the International Society of Hypertension. J Clin Hypertens (Greenwich) 2014;16:14-26.
- Nerenberg KA, Zamke KB, Leung AA, et al. Hypertension Canada’s 2018 Guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol 2018. [Epub ahead of print].
- Diabetes Canada Clinical Practice Guidelines Expert Committee. Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes 2018(Suppl 1): S1-325.
- Adler A, Stratton IM, Neil HA, et al. Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000;321:412-9.
- UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998;317:703–13.
- Hypertension Canada. Treatment of hypertension in association with diabetes mellitus. http://guidelines.hypertension.ca/prevention-treatment/hypertension-with-diabetes/. (Accessed April 11, 2018).
- Grossman A, Grossman E. Blood pressure control in type 2 diabetes patients. Cardiovasc Diabetol 2017;16:3. doi: 10.1186/s12933-016-0485-3.
- Hypertension Canada. Choice of therapy for adults with hypertension without compelling indications for specific agents. http://guidelines.hypertension.ca/prevention-treatment/uncomplicated-hypertension-therapy/. (Accessed April 11, 2018).
- Leung AA. Daskalopoulou SS, Dasgupta K, et al. Hypertension Canada’s 2017 guidelines for diagnosis, risk assessment, prevention, and treatment of hypertension in adults. Can J Cardiol 2017; 33(5): 557-576.
- Schrier RW, Estacio RO, Esler A, Mehler P. Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopaty and strokes. Kidney Int 2002;61:1086-97.
- Wan EYF, Yu EYT, Chin WY, et al. Effect of achieved systolic blood pressure on cardiovascular outcomes in patients with type 2 diabetes mellitus: a population-based retrospective cohort study. Diabetes Care 2018 Mar 28. doi: 10.2337/dc17-2443.
Cite this document as follows: Clinical Resource, Hypertension in Patients With Diabetes. Pharmacist’s Letter/Prescriber’s Letter. May 2018.