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Management of Hypertension in Diabetes Mellitus Sidhartha Das*, Rina Mohanty**, UK Patnaik*** demands special attention, more so in Indian scenario. Higher prevalence of hypertension(HTN) amongst diabetics in India has been reported since 19851. Review on the subject by 2. Hypertension consequent to nephropathy Das in 1995 (on Indian data) had revealed the prevalence to be as variable as 7 per cent in 4. Supine hypertension with orthostatic fall Cuttack to 30.9 per cent at Sevagram2. Further,there was a variable difference between IDDM (Type-1) and NIDDM (Type-2) i.e., 10 versus32 per cent respectively in diabetics from Mumbai2. Recent studies from Manipal revealed B. Insulin resistance leading to abnormalities in : about 40 per cent diabetics to be hypertensive3.
Such higher prevalence of HTN could partly be ii Transmembrane ion exchange in vascular due to better assessment in diabetics but most likely on par with change of lifestyle and iv Prostaglandin kallikrein/kinin system.
diseases in diabetics will account for 5 to 20 per cent of the total health care expenditure. A viii Sympathetic nervous system involvement.
number of modifiable arterial risk factors cardiovascular disease (CVD) in patients withdiabetes mellitus (DM)4. HTN is one of the modifiable arterial risk factors for developing CVD. Its management is not always easy and Despite the fact that patients who suffer from both published evidence suggests that failure of DM and HTN could represent a complex entity as clinical management is not uncommon. It is regards developing CVD, short comments have therefore necessary that specific guidelines be been made in the JNC VI report on the treatment laid down for the treatment of HTN in Indian of HTN in diabetic subjects5. In view of the importance of the problem the issue needs to bediscussed under three specific areas, viz.: * Addl. Professor & Unit HeadPG Department of Medicine 1. Which measurement of arterial blood pressure 2. Which arterial pressure target value should be Department of CardiologySCB Medical College & Hospital, use the higher category amongst the two for HTN is defined as systolic blood pressure (SBP) Supine, sitting, and standing blood pressure of 140 mmHg or greater and/or diastolic blood should be measured in all diabetic subjects5. This pressure (DBP) of 90 mmHg or greater5. The is an important issue in diabetic patients where object of identifying and treating high blood autonomic neuropathy often leads to supine HTN pressure is to reduce the risk of CVD and with postural fall of blood pressure. Arterial blood associated morbidity and mortality. It is pressure measured in the sitting position should therefore imperative to provide a classification of blood pressure in adults so as to identify thehigh risk individuals and to provide guidelines Table I : Classification of blood pressure for The important question is : To which level should the blood pressure be reduced in a diabetichypertensive patient? This has not been clearly answered, even though arguments for a lower target blood pressure for diabetics has been recommended6. There is no specific guideline on the exact values for HTN control in diabetics. In several official recommendations, a definition is given as to what is meant by optimum, fair, acceptable, or poor control keeping in view the population under consideration. The necessary Where SBP and DBP fall into different categories, Table II : Targets for HTN control in diabetic subjects belonging to various geo-ethnic origin.
Specific guidelines on HTN in diabeticsUnited Kingdom working party12 a : In absence of nephropathy, otherwise ≤ 135/85 mmHg.
b : Not enough evidence to recommend a target value for SBP in patients with microalbuminuria. It may be worth attempting to achieve a DBP of approximately 80 mmHg.
c : Similar to recommendations by the National High Blood Pressure Education Program Working Group16 and the d : In the absence of nephropathy, otherwise ≤ 140/80 mmHg.
Journal, Indian Academy of Clinical Medicine Vol. 2, No. 1 January-March 2001 It is worth noting that in a subgroup of 1,501 for the patient under consideration. For such patients with DM, in the Hypertension Optimal reasons, central adrenergic antihypertensives are not considered to be of first choice. According to cardiovascular events was halved in the group the European NIDDM Policy Guidelines, thiazides randomised to a DBP ≤ 80 mmHg when compared may be used in small doses and low doses of with the target group with DBP < 90 mmHg17. It cardioselective beta-blockers are to be preferred was concluded that active lowering of blood in order to avoid metabolic interference7. The pressure was particularly beneficial in the ALFEDIAM guidelines consider beta-blockers to be useful antihypertensive agent in diabetics with reduction of DBP to values of 80 mmHg or below coronary artery disease, while alpha 1 adrenergic blockers were not taken into account15. On theother hand, potentially favourable effects of alpha 1 blockers on the lipid profile makes them thefirst line therapy in the ADA statement14. These In diabetic patients, particularly those with mild to drugs, in addition to HTN also reduce insulin moderate HTN, the first line of treatment includes resistance without influencing glucose metabolism.
lifestyle modification, i.e., weight control, low fat Despite numerous guidelines, none give precise anti-atherogenic diet, salt restriction, reduction in indications of a first choice drug for treatment or alcohol intake, discontinuation of smoking, and the best pharmacological combination. This supervised regimens of physical activity.
percentage of diabetics are not controlled, with antihypertensive drugs. Five classes of drugs are considered to be effective for monotherapy.
It has long been understood that the choice of Diuretics, beta-blockers, calcium channel blocker, antihypertensive drugs in diabetic patients with alpha 1 adrenergic blockers, ACE-inhibitors, and incipient nephropathy should be an ACE-inhibitor.
likely angiotensin-receptor antagonists are the ACE-inhibitors also prolong bradykinin action armamentarium of first line drugs available for which potentiates insulin induced glucose uptake use in India. In the absence of randomised and therefore enhance insulin sensitivity. However, controlled large scale clinical trials on the various diabetics with rising azotaemia, i.e., serum classes of antihypertensive agents in diabetic creatinine value above 2.5 mg/dl should not be patients with HTN, the choice of treatment is based on our understanding of the pathophysiology of HTN in diabetics and known pharmacologicalaction as well as side-effects of the drug to be If the target blood pressure of 130/85 is not achieved with the use of ACE-inhibitor alone,addition of low dose diuretic is recommended18.
Antihypertensive medications should not adversely Interestingly the nephroprotective effect of ACE- affect carbohydrate and lipid metabolism. Keeping in view the likely reason for HTN in a diabetic, microalbuminuric normotensive patients with Type- any of the above-mentioned group of drugs can be used. However, the therapeutic implications comparing the efficacy of atenolol with captopril have to take into consideration the existence/ in reducing the risk of macrovascular and absence of any concurrent disease/complication microvascular complications in Type-2 diabetics viz., IHD, CHF, Nephropathy, PVD. Then the issue (vast majority of Indian diabetics are Type-2) did to be considered is the efficacy, tolerance, safety not observe any difference in such end points19.
and, in India, the cost effectiveness of the drug Moreso, urinary albumin excretion was reduced Journal, Indian Academy of Clinical Medicine Vol. 2, No. 1 and 2 January-June 2001 to a similar extent in both the groups of diabetics.
Hypertension 1997; 15 (Suppl 2): S63-5.
This study did not provide evidence that either drug 7. Albert KGMM, Gries FA, Jervell J et al. For the Europian had any specific beneficial or deleterious effect NIDDM Policy Group, A desktop guide for themanagement of non-insulin-dependent diabetes mellitus and leads to the conclusion that control of HTN (NIDDM): an update. Diab Med 1994; 15: 899-909.
itself may be more important than the treatment 8. Asian-Pacific NIDDM Policy Group. Non-insulin dependent diabetes mellitus (NIDDM). Practical targetsand treatments. Sydney : Health Communications, In diabetics with isolated systolic HTN, diuretics are of greater benefit. Natriuretic calcium-channel 9. European IDDM Policy Group 1993. Consensus blockers like nitrendipine may be more suitable guidelines for the management of insulin-dependent for diabetics with systolic HTN and mild diastolic (Type-I) diabetes mellitus. Diab Med 1993; 10: 990-1005.
10. Expert Committee of the Canadian Diabetes Advisory Board. Clinical practice guidelines for treatment of 11. World Health Organisation. Management of diabetes mellitus. Standards of care clinical practice guidelines.
diabetics offered in this article are on evidence Diabetes prevention and control. WHO-EM/DIA/6/E/G.
based consensus and it seems that a more strict Geneva : World Health Organisation 1994; 27-9.
control of HTN is required in diabetics as 12. A Working Party (UK). Blood pressure and diabetes : compared to nondiabetic hypertensives. While the Everyone’s concern. Clineham : RR Assoc 1994.
13. Dawson KG, KcKenzie JK, Ross SA et al. Report of the drug of first choice to lower HTN in a diabetic is Canadian Hypertension Society Consensus Conference: often decided to a larger extent by the presence 5. Hypertension and Diabetes. Can Med Assoc J 1993; complications, as per the UKPDS results, control 14. ADA Consensus Statement. Treatment of hypertension of HTN and maintainance of ideal blood pressure in diabetes. Diab Care 1996; 19: S107-13.
is the moot point that would benefit the diabetic 15. Bauducean B, Chatellier G, Cardonnier D et al.
Recommendations de 1’ALFEDIAM. Hypertension et diabete. Diabete Metabol 1996; 22: 64-76.
16. National High Blood Pressure Education Program Working Group. Report on hypertension in diabetes.
Hypertension 1994; 23: 145-58.
1. Patel JC. Diabetes and its complications. J Diab Assn 17. Hansson L, Zanchetti A, Carruthers SG et al. Effects of intensive blood-pressure lowering and low-dose aspirin 2. Das S. Etiopathogenesis of hypertension in diabetes in patients with hypertension : Principal results of the mellitus. Int J Diab Dev Count 1995; 15: 106-09.
Hypertension Optimal Treatment (HOT) randomised trial.
3. Rau NR, Acharya RV, Shah S. Incidence of diabetic complications in newly detected cases of NIDDM. Nova 18. Bennett PH, Haffner S, Kasiske BL et al. Screening and Nordisk Diabetes Update Proceedings 1999, Helath Care management of microalbuminuria in patients with Communications, Bangalore 1999; 35-6.
diabetes mellitus : Recommendations to the Scientific 4. Kumar A. Indian scenario – hypertension. In : Das S Ed.
Advisory Board of the National Kidney Foundation from Complications of Diabetes in Indian Secnario, an Ad Hoc Committee of the Council on Diabetes Mellitus proceedings Vol. 1. USV Ltd. Mumbai 2000.
of the National Kidney Foundation. Am J Kidney Dis 5. The Sixth Report of the Joint National Committee on Prevention, Detection, Education and treatment of High 19. UK Prospective Study Group. Efficacy of atenolol and Blood Pressure. Arch Int Med 1997; 157: 2413-46.
captopril in reducing risk of macrovascular and 6. Ruilope LM, Garcia-Robles R. How far should blood microvascular complications in type 2 diabetes : UKPDS pressure be reduced in diabetic hypertensive patients? J 39. Br Med J 1998; 317: 713-20.
Journal, Indian Academy of Clinical Medicine Vol. 2, No. 1 and 2 January-June 2001

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