W7 Diabetes with Hypertension (PD)

Question 1

Why is it important to lower BP in patients with diabetes?

Answer 1

• Hypertension in patients with
  diabetes should be treated aggressively with lifestyle modification and drug treatment.
• Lowering blood pressure in patients with diabetes reduces the risk of macrovascular and microvascular complications.

Macro= CVD and Stroke
Micro= Neuropathy, Retinopathy, Nephropathy, Dementia, dyslipidemia, DKA, infections, reduced QOL

Question 2

Hypertension in Diabetes type 2- management NICE CKS
Newly diagnosed:

Answer 2

Reinforce the importance of lifestyle advice.
Confirm a diagnosis of hypertension in a person with clinic blood pressure of 140/90 mmHg or higher and ABPM daytime average or HBPM average of 135/85 mmHg or higher.
Measure standing as well as seated blood pressure.
Classify the person’s stage (1, 2, 3) of hypertension.
Assess whether antihypertensive treatment is needed, depending on the stage of
hypertension, person’s age, estimated 10-year cardiovascular risk, evidence of target
organ damage, and co-morbidities (including frailty or multimorbidity).

Question 3

Hypertension in Diabetes type 2- management NICE CKS
If antihypertensive drug treatment is indicated:

Answer 3

• Assess the person’s treatment goals and preferences and explain the risks and benefits of drug treatment.
• Offer a generic angiotensin-converting enzyme (ACE) inhibitor or angiotensin-II receptor antagonist (AIIRA) to all adults (of any age or ethnic origin).
• For adults of black African or African-Caribbean origin, consider an AIIRA in preference to an ACE inhibitor.
• If an ACE inhibitor is not tolerated, offer an AIIRA.
• Do not combine an ACE inhibitor with an AIIRA to treat hypertension
• Offer a calcium-channel blocker (CCB) or thiazide-like diuretic in addition to an ACE
  inhibitor or AIIRA, if hypertension is not controlled by monotherapy.
• Offer a combination of an ACE inhibitor or AIIRA, a CCB and a thiazide-like diuretic if
  hypertension remains uncontrolled.

Question 4

Hypertension in Diabetes type 1 – management NICE CKS:
What are the steps?

Answer 4

1. Start a trial of a renin-angiotensin system blocking drug as first-line treatment for
   hypertension in adults with type 1 diabetes.
2. Offer an angiotensin-converting enzyme (ACE) inhibitor, provided there are no
   contraindications. If an ACE inhibitor is not tolerated, offer an angiotensin-II receptor
   antagonist (AIIRA) if appropriate.
3. Start with a low dose and titrate up to the maximum tolerated therapeutic dose (within the maximum licensed dose) by doubling the dose every 1–2 weeks.
4. After each upward titration, monitor the person’s renal function, serum potassium level, and blood pressure

Be aware that it may be necessary to prescribe other antihypertensive drugs to
improve blood pressure control.
Do not avoid cardio-selective beta-blockers (such as ??) where indicated in adults
on insulin.
Low-dose thiazides may be combined with beta-blockers.
When calcium-channel blockers are prescribed, use only long-acting preparations.

Question 5

Cardioselective beta blocker examples:
Non-selective:

Answer 5

Atenolol, bisoprolol, metoprolol

Propanalol, carvedilol, sotalol

Question 6

Hypertension in Diabetes
NICE NG17/CKS:

In adults on antihypertensive treatment aged < 80 years with DM, aim for what clinic BP targets?
>80 years?

Answer 6

• If the urine ACR < 70 mg/mmol: below 140/90 mmHg;
• If the ACR is > 70 mg/mmol: below 130/80 mmHg.

In adults aged > 80 years, aim for a clinic blood pressure < 150/90 mmHg, regardless of the
patient’s ACR.

Question 7

Signposting: Where to signpost?

Answer 7

The Diabetes UK patient resource Diabetes and blood pressure may be helpful

Question 8

SIGN 116 (Management of diabetes)
Primary prevention of coronary heart disease

Answer 8

• Hypertension in people with diabetes should be treated aggressively with lifestyle
  modification and drug therapy
• SIGN recommends a clinic target blood pressure <130/80 mmHg.
• If drug treatment is required, start a trial of a renin–angiotensin system blocking drug as
  first-line treatment for hypertension or a calcium channel blocker or a thiazide diuretic
  Hypertension in Diabetes

Question 9

Mrs Sarah Morris, a 35-year-old female patient, was diagnosed with hypertension. Her
past medical history shows that she’s been diagnosed with type 2 diabetes for which
she was prescribed metformin 500mg tablets three times a day.

Assuming her kidney function is good, she’s not pregnant and she has no recorded
allergies, which of the following would be the most appropriate first line treatment for
hypertension stage 1?

A. Labetalol
B. Nifedipine
C. Losartan
D. Bendroflumethiazide
E. Amlodipine
F. Ramipril
G. Bisoprolol
H. Methyldopa

Answer 9

= F
ACEI are the first line in management of diabetic hypertensives. They reduce the macrovascular and microvascular risks associated with diabetic hypertensives