Evidence-based approach for managing hypertension in type 2 diabetes

Integrated Blood Pressure Control Dovepress open access to scientific and medical research Review Integrated Blood Pressure Control downloaded from https://www.dovepress.com/ by 88.99.76.109 on 31-Jul-2020 For personal use only. Open Access Full Text Article Evidence-based approach for managing hypertension in type 2 diabetes This article was published in the following Dove Press journal: Integrated Blood Pressure Control 24 May 2010 Number of times this article has been viewed Gerti Tashko 1 Robert A Gabbay 2 Division of Endocrinology, Diabetes, and Metabolism, Penn State College of Medicine, Hershey, PA, USA; 2Penn State Institute for Diabetes and Obesity, Penn State College of Medicine, Penn State Milton S Hershey Medical Center, Hershey, PA, USA 1 Introduction Correspondence: Robert A Gabbay, MD, PhD Diabetes Program, Penn State Milton S Hershey Medical Center, 500 University Drive, H044, Room C6630, Hershey, PA 17033, USA Tel +1 (717) 531-3592 Fax +1 (717) 531-5726 Email submit your manuscript | www.dovepress.com Dovepress 6984 Powered by TCPDF (www.tcpdf.org) Abstract: Blood pressure (BP) control is a critical part of managing patients with type 2 diabetes. Perhaps it is the single most important aspect of diabetes care, which unlike hyperglycemia and dyslipidemia can reduce both micro- and macrovascular complications. Hypertension is more prevalent in individuals with diabetes than general population, and in most cases its treatment requires two or more pharmacological agents (about 30% of individuals with diabetes need 3 or more medications to control BP). In this article we describe the key evidence that has contributed to our understanding that reduced BP translates into positive micro- and macrovascular outcomes. We review the data supporting current recommendation for BP target , 130/80 mmHg. Two studies suggest that a lower BP goal could be even more beneficial. We also present the comparative benefits of various antihypertensive drugs in reducing diabetes-related micro- and macrovascular complications. Finally we propose an evidence-based algorithm of how to initiate and titrate antihypertensive pharmacotherapy in affected individuals. Overall, achieving BP , 130/80 mmHg is more important than searching for the “best” antihypertensive agent in patients with diabetes. Keywords: blood pressure control, treatment protocol, fixed dose combination, clinical inertia, adherence Diabetes is very prevalent and places high financial burden to our society. In the United States during 2009 to 2034 the number of persons with diabetes is anticipated to increase from 23.7 million to 44.1 million. The relative annual cost is also expected to rise from $113 billion to $336 billion during the same period.1 Worldwide, 366 million individuals are projected to have diabetes by year 2030.2 Type 2 diabetes, the predominant form, comprises 90% to 95% of all cases. Macrovascular disorders are common in affected individuals. Specifically, cardiovascular disease (CVD) is 2 to 5 times more prevalent in persons with diabetes than general population.3–5 Importantly it is the most serious complication by contributing 70% to all-cause mortality in affected patients.6 In the United States, diabetes is also the leading cause of microvascular disorders of end stage renal disease (ESRD)7,8 and retinopathy.9 Hypertension is 1.5 to 2.0 times more common in patients with diabetes than without diabetes,10 and more so in females than males.11 For example, about 40% of individuals between ages 25 to 65 already have high blood pressure (BP) at the time of diagnosis of diabetes.11 This figure increases further with age.4,11 Coexistence of hypertension with diabetes is likely due to the confounding effect of metabolic syndrome that often predates both conditions. Integrated Blood Pressure Control 2010:3 31–43 31 © 2010 Tashko and Gabbay, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. Integrated Blood Pressure Control downloaded from https://www.dovepress.com/ by 88.99.76.109 on 31-Jul-2020 For personal use only. Tashko and Gabbay Hypertension is not only common but also a major cause of cardiovascular (CV) pathology11–14 and thus mortality in individuals with diabetes. It is also a direct contributor to microvascular complications of nephropathy 7,15,16 and retinopathy.16–18 As described in the main text, many randomized clinical trials have documented that good BP control reduces both micro- and macrovascular complications. This could make hypertension the single most important determinant of diabetes-related morbidity and mortality compared to hyperglycemia that mainly causes microvascular disease and dyslipidemia that mostly contributes to macrovascular complications. For this review article, we searched the literature for clinical studies related to treatment of hypertension in type 2 diabetes. We utilized PubMed to find trials published in 2005 to 2010. We then used citations from identified articles to select landmark studies printed before 2005. For this paper we chose mainly randomized clinical trials with large sample size and long duration of follow up. We narrowed further our selection to original works that emphasized renal and CV outcomes of various antihypertensive therapies in subjects with type 2 diabetes. The purpose of this article is 5-fold. First, to provide evidence that reducing BP is beneficial in patients with diabetes; second, to demonstrate that optimal BP target is ,130/80 mmHg; third, to show that hypertension is poorly controlled in clinical practice worldwide; fourth, to explain the rationale of choosing the right antihypertensive medications; and fifth, to provide a descriptive algorithm of how to initiate and titrate pharmacotherapy. Reducing BP is beneficial Critical evidence from 2 major trials, UKPDS18,19 and SHEP,20 shows that reduced BP prevents complications in patients with type 2 diabetes. UKPDS 3818 was a landmark study that examined if decreased BP in persons with new type 2 diabetes lowered micro- and macrovascular complications. At study entry, 1148 subjects with less than 3 years of diabetes and mean BP 164/94 mmHg were randomized into “tight” BP and “less-tight” BP control groups. Patients in the tight BP control group received either angiotensin converting enzyme inhibitor (ACEi) captopril or β-blocker atenolol to bring BP to ,150/85 mmHg. The less-tight BP control group could use medications other than ACEi or β-blocker to attain BP ,180/105 mmHg. After 8.4 years of follow up, the tight BP control group achieved a lower BP than the less-tight BP control arm 32 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress Dovepress (∆10/∆5 mmHg), resulting in greater relative reductions (P , 0.05) for both micro and macrovascular complications: 24% in any diabetes related end-points (...truncated)