Blood Pressure Control at the Diabetes Planned Visit

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Diabetes planned visits address several health topics of concern to the diabetic patient, including high blood pressure. This document offers a guideline for developing a blood pressure goal.

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Blood Pressure Control

BP control (<130/70) reduces MI, stroke and death more than blood sugar control.

• BP of 132/79 reduces all cause mortality 49% (ABCD study).
• Hypertension contributes to up 75% of diabetes related complications.
• 80% of people with diabetes die of heart attacks and strokes.
• Risk of cardiovascular disease doubles for every increase of 20 mm Hg in systolic blood pressure and every 10 mm Hg diastolic blood pressure starting at 115/75.

BP goal is <125/70 if proteinuria is present or GFR <60.

Each 10 mmHg reduction of systolic blood pressure reduces:

• Diabetic complications 12% , myocardial infarction 11%, microvascular complications 13%.

Stepwise approach to reaching blood pressure goal in DM^a

Step 1: Lifestyle modification:^b

• Low-sodium, high potassium, low calorie, high-fiber foods.
• Increased physical activity (Walking to 35 to 45 minutes 3 to 5 days/week).

Step 2: Thiazide diuretic (HCTZ , chlorthalidone).

Step 3: Add ACE inhibitor.

Step 4: If diabetic nephropathy (microalbuminuria ≥30) present or GFR <60:^a,c

Add ARB to ACE

• ACE and ARB titrated to target dose even if at goal BP.

Step 5: Add beta blocker (BB) or calcium channel blocker (CCB):

1. BB first if S/P MI, CABG or angioplasty.
2. Use long acting non dihydropyridine channel blocker (CCB).
   e.g., verapamil, diltiazem.

Step 6a: If pulse greater than or equal to 84:

• Add low-dose beta blocker^d or alpha blocker.

• If still not at target add at long acting alpha blocker^e or low dose beta blocker nightly.

Step 6b: If baseline pulse is <84:

• Add other subgroup of calcium channel blocker.
  (e.g., amlodipine if verapamil   or diltiazem has been used)

Step 7: Consider referral to nephrologist or cardiologist if not at target BP.

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a.  Always include lifestyle modification.
b. Move through successive steps until goal BP is reached.
c. Use steps 1-4 if microalbuminuria / proteinura or GFR < 60 cc/min,  regardless of BP.
d. Special note: Use of beta blocker with a nondihydropyridine CCB (verapamil, diltiazem) should be avoided in the elderly and those with conduction abnormalities, instead choose hydralazine, clonidine, minoxidil or methyldopa.
e. Special note: Clonidine should not be used with beta blockers because of the risk of severe bradycardia.

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Causes of inadequate response to antihypertensive therapy

• Excess salt intake.
• Progressive renal damage.
• EtOH  >2 oz. per day.
• Fluid retention.
• Inadequate diuretic therapy.
• Obesity.
• Smoking.
• NSAIDs.
• Sleep apnea.
• Antidepressants.
• Oral contraceptives.
• Caffeine.
• Appetite suppressants.

Diuretics

Hydrochlorothiazide (HCTZ)

• Typical hydrochlorothiazide dose 12.5 mg-25 mg daily.
• Ineffective if creatinine clearance <30 cc/min, creatinine >2.5. 

Loop diuretics (furosemide, Lasix)

• Most effective if creatinine clearance <30 to 40 cc/min.
• High doses given twice daily may be needed.

Beta blockers (BB)

• ß-1 selective BB do NOT increase the risk of masking hypoglycemia.
• Propranolol may reduce tremulousness/hunger, not diaphoresis/impaired cognition.
• Consider cardioselective BB agent (carvedilol [Coreg]); Improves insulin sensitivity.
• Monitor for; bradycardia, CHF, wheezing fatigue, insomnia, cold extremities.

Calcium channel blockers (CCBs)

• Use only long acting formulations.
• Only amlodipine should be used in CHF.
• Monitor for ankle edema, dizziness, flushing and headache.

Non-dihydropyridines

• Verapamil, diltiazem.

Dihydropridines

• Amlodipine, nisoldipine, felodipine, isradipine, nicardipine.
• Nifedipine (do not use to treat hypertension).

Verapamil (Effective Max 240mg/day)

• Preferred calcium channel blocker.
• Contraindications: AV node dysfunction with 2^nd or 3^rd  degree AV block, systolic heart failure, decreased LV function.
• Monitor for bradycardia and heart block.

Diltiazem (Max 480 mg)

• May use in atrial fibrillation, angina, ischemia.

ACE/ARB 

• Consider holding diuretic for 24-48 hours prior to beginning ACE to avoid hypotension.
• Obtain baseline serum potassium, creatinine and BUN, repeat BMP within 2 weeks.

Rising creatinine > 30% above baseline

• Usually due to volume depletion, thus not a reason to avoid ACE indefinitely.
  • If creatinine rises > 30, but < 50%, hold ACE and diuretic, normalize volume status, and repeat BMP in 4-7 days.
  • Resume ACE when creatinine at baseline.
• Renal artery stenosis is a contraindication to ACE ARB.
  • Suspect if, in the absence of heart failure and volume depletion, creatinine rises >30%.
  • Suspect if creatinine continue to rise over 1^st 2 months of therapy.
  • Suspect if creatinine rises > 50% from baseline.

Lisinopril (Start 5-10 mg QD, double Q 2weeks, Max 80mg QD)

Losartan (Cozaar) Start 25mg QD, double Q 2 weeks, Max 100mg QD)

Valsartan (Diovan) Start 40mg QD, double Q 2 weeks Max 320mg QD)

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