This is the current release of the guideline.

Hypertension in patients with type 2 diabetes mellitus

Management
Risk Assessment
Treatment

Endocrinology
Family Practice
Internal Medicine

Advanced Practice Nurses
Allied Health Personnel
Nurses
Physician Assistants
Physicians

To provide clinicians with evidence-based recommendations regarding treatment of hypertension in type 2 diabetes mellitus: setting treatment goals, choosing optimal agents for treatment, and setting priorities in patients with type 2 diabetes

Type 2 diabetes patients with concomitant hypertension, including patients with some form of microvascular complications and premenopausal women.

Treatment/Prevention

Antihypertensive Drugs

1. Thiazide diuretics
2. Calcium-channel blockers
3. Beta-blockers
4. Angiotensin-converting enzyme (ACE) inhibitors
5. Angiotensin-II receptor blockers
6. Alpha-blockers (should be reserved for hypertension refractory to other agents)

• All-cause mortality
• Cardiovascular mortality
• Cardiovascular events (myocardial infarction, stroke, congestive heart failure)
• Microvascular complications (photocoagulation, nephropathy, neuropathy, amputation)

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The literature review was limited to randomized, controlled trials that included patients with diabetes. Only studies that measured major clinical end points were included. Four classes of clinical end points were defined: all-cause mortality, cardiovascular mortality, major cardiovascular events (that is, myocardial infarction or stroke), and advanced microvascular outcomes (photocoagulation or visual loss, nephropathy or end-stage renal disease, neuropathy, or amputation). The authors separated the literature review into two categories. The first category evaluated the effects of hypertension control if the comparison examined an antihypertensive drug versus placebo or the effects of different target blood pressure levels. The second category evaluated the effects of different classes of drugs.

Several sources were used to identify the relevant literature. For older literature, the authors started with the Cochrane Collaboration Diabetes Group report on treatment of hypertension in diabetes, which was published in 1997. This report has now been withdrawn because it is out of date, but it served as a reasonable starting point to identify pre-1997 literature. A MEDLINE search was then performed in May 2000 and updated in April 2002. The authors used the keywords exp diabetes mellitus and exp hypertension [therapy or prevention and control] and limited the search to randomized, controlled trials. The final search produced 322 results. Of these, most were discarded because they did not measure major clinical outcomes, were observational in nature, were reviews or editorials, or did not primarily address the issue of treatment of hypertension. The search was then updated through consultation with experts and through examining references from meta-analyses and review articles.

322 articles

Not stated

Not applicable

Systematic Review with Evidence Tables

Data were extracted from the primary study reports by the primary author and were reviewed by the senior author. Accuracy and quality of the abstraction were confirmed through reabstraction and comparison with the original abstraction. The outcomes were broken into categories as described, and data on absolute and relative risk reduction and numbers needed to treat for benefit were derived from the primary reports or were calculated in standard fashion.

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

This paper was developed by the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP). It was peer reviewed by the American Diabetes Association, the National Diabetes Education Program (National Heart, Lung, and Blood Institute), and the American Academy of Family Physicians. Approved by the ACP Board of Regents in October 2001.

Recommendation 1: Blood pressure control must be a priority in the management of persons with hypertension and type 2 diabetes.

Recommendation 2: Clinicians should aim for a target blood pressure of no more than 135/80 mm Hg for their patients with diabetes.

Recommendation 3: Thiazide diuretics or angiotensin-converting enzyme (ACE) inhibitors can be used as first-line agents for blood pressure control in most patients with diabetes.

Recommendation 4: Further studies are warranted on the relative contributions of glucose control and blood pressure control to clinical outcomes such as microvascular and macrovascular complications.

None provided

The recommendations are supported by data from randomized controlled trials that included patients with diabetes. See related background article: Vijan S, Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med 2003 Apr 1; 138(7): 593-602.

• Improved blood pressure control
• Reduction in overall mortality
• Reduction in cardiovascular events and microvascular complications

In the United Kingdom Prospective Diabetes Study (UKPDS) patients taking beta-blockers gained more weight than those taking angiotensin-converting enzyme (ACE) inhibitors, and beta-blocker therapy was more frequently discontinued. In addition, patients taking beta-blockers required the addition of new glucose-lowering agents more frequently than those taking ACE inhibitors.

• Clinical practice guidelines are "guides" only and may not apply to all patients and all clinical situations. Thus, they are not intended to override clinicians' judgment.
• All American College of Physicians (ACP) clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.

An implementation strategy was not provided.

Getting Better
Living with Illness

Effectiveness

Not applicable: The guideline was not adapted from another source.

2003 Apr 1

American College of Physicians - Medical Specialty Society

American College of Physicians

Clinical Efficacy Assessment Subcommittee (CEAS)

Authors: Vincenza Snow, MD; Kevin B. Weiss, MD; Christel Mottur-Pilson, PhD

Clinical Efficacy Assessment Subcommittee Members: Kevin Weiss, MD (Chair); Mark Aronson, MD; Patricia Barry, MD; Nick Fitterman, MD; E. Rodney Hornbake, MD; Keith Michl, MD; Doug Owens, MD; Allan Ronald, MD; Katherine Sherif, MD

None disclosed

This is the current release of the guideline.

This NGC summary was completed by ECRI on July 9, 2003. The information was verified by the guideline developer on July 23, 2003.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.