Antihypertensives for diabetic patients
Ensure patients with diabetes are being treated with appropriate anti-hypertensives to reach a blood pressure target of 130/80. For patients with albuminuria this should include an ACEi/ARB titrated to maximum tolerable dose.
Clinical notes
For patients with diabetes and albuminuria or coronary artery disease, ACEi/ARB is first line and should be adjusted to the maximum tolerable dose (i.e. probably no lower than 100/60). Otherwise, reasonable first options include ACEI/ARB, CCB, or thiazide diuretic. If BP remains >130/80, uptitrate and add from the remaining of the above 3 classes until maxed out, then consider spironolactone as 4th option. There have been no RCTs to demonstrate a decreased incidence of CV events in people with diabetes by targeting BP <130/80; SPRINT excluded people with diabetes and ACCORD did not show a target of <120 helped reduce CV event rates. More recently, STEP did include nearly 20% of people with diabetes and found that a SBP target of <130 was superior to <150 for reducing a composite of cardiovascular events. Meta-analyses have also shown improved outcomes in people with diabetes with a mean BP of 133/76 vs mean 140/81, hence recent ADA guidelines have come down from the prior recommendation of <140/90. ADA Diabetes standards of care 2023 recommendation 10.4 states people with diabetes and hypertension qualify for antihypertensive drug therapy when the blood pressure is persistently elevated >= 130/80. The on-treatment target BP goal is <130/80, if it can be safely attained. ADA Recommendation 10.13 states individuals with Hypertension who are not meeting BP targets in 3 classes of antihypertensive medications (including a diuretic) should be considered for MRA therapy.
