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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.
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
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
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.
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. Effects of
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. Screening and
Nordisk Diabetes Update Proceedings 1999, Helath Care
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Advisory Board of the National Kidney Foundation from
Complications of Diabetes in Indian Secnario,
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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
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Journal, Indian Academy of Clinical Medicine Vol. 2, No. 1 and 2 January-June 2001
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