What are the preferred drugs for Hypertension in diabetic patients?

1.

Elsevier ClinicalKey Clinical Overview

Treatment Diabetes Approximately 80% of patients with diabetes have systolic blood pressure of 130 mmHg or higher or diastolic blood pressure of 80 mmHg or higher or are taking prescription medication for their high blood pressure Hypertension is a modifiable risk factor for cardiovascular complications and progression of diabetic kidney disease Blood pressure targets in patients with diabetes differ according to type of diabetes and degree of impairment in kidney function ACE inhibitors are generally the first line agent for treating hypertension in patients with diabetes and chronic kidney disease; angiotensin receptor blockers are an alternative if ACE inhibitor therapy is contraindicated or not tolerated Thiazide diuretics may cause hyperglycemia; consider increased monitoring of glucose levels Chronic kidney disease Hypertension is the most common cause of chronic kidney disease; conversely, chronic kidney disease can lead to or exacerbate hypertension Target systolic blood pressure of lower than 120 mm Hg is recommended ACE inhibitor or angiotensin receptor blocker is recommended for patients with high blood pressure, chronic kidney disease, or moderate or severely increased albuminuria, with or without diabetes Treat adult kidney transplant recipients with a dihydropyridine calcium channel blocker or angiotensin receptor blocker to a target blood pressure of lower than 130 mm Hg Sodium intake should be less than 2 g/day (equivalent to 5 g of sodium chloride) for most patients Progressive azotemia and hyperkalemia are possible; periodic laboratory monitoring is recommended

2.

Dhatariya, Ketan K., Umpierrez, Guillermo E., Crandall, Jill P. (2024). In Goldman-Cecil Medicine (pp. 1534). DOI: 10.1016/B978-0-323-93038-3.00210-0

Hypertension (Chapter 64), which is a common comorbid condition in diabetes, increases the risk of microvascular and macrovascular complications. The blood pressure goal should be less than 130/80 mm Hg for most people with diabetes. ACE inhibitors and angiotensin receptor blockers are generally considered first-line therapy for patients with diabetes (Chapter 64), but β-blockers, calcium-channel blockers, and low-dose diuretics are also recommended as add-on therapy if needed to achieve blood pressure targets. However, β-blockers should be used with caution in patients at high risk for hypoglycemia because they may blunt the autonomic warning symptoms associated with low glucose concentration.

3.

Harris, Raymond C. (2024). In Goldman-Cecil Medicine (pp. 795). DOI: 10.1016/B978-0-323-93038-3.00109-X

Elevated blood pressure is an important risk factor in the progression of diabetic nephropathy. To slow the progression of diabetic nephropathy, some guidelines recommend a blood pressure goal of <140/90mm Hg whereas others recommend a target of <130/80 mm Hg.14–16 Medications that interfere with the renin-angiotensin system, either ACE inhibitors or angiotensin receptor blockers, are the preferred agents (seeTables 64-8and64-9), with calcium-channel antagonists as second-line therapy.SGLT2 inhibitors also lower blood pressure and can reduce the need for additional antihypertensive agents. Because of the high prevalence of type IV renal tubular acidosis (Chapter 104) and renal artery stenosis (Chapter 110) associated with diabetic nephropathy, patients treated with ACE inhibitors or angiotensin receptor blockers should have their serum potassium and creatinine levels monitored closely in the first week after the initiation of therapy. If blood pressure control is not achieved with these agents, diuretics and other antihypertensive agents, including cardioselective β-blockers, α-blockers, and nondihydropyridine calcium-channel blockers, can be added (Chapter 64).Dihydropyridine calcium-channel blockers induce selective afferent arteriolar vasodilation and may increase intraglomerular capillary pressure, so they are usually reserved for patients who do not achieve blood pressure control with other agents.

4.

Marx, Nikolaus, Inzucchi, Silvio E., Mcguire, Darren K. (2022). In Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine (pp. 556). DOI: 10.1016/B978-0-323-72219-3.00031-1

Four classes of antihypertensive medications reduce CVD risk in patients with DM: ACE inhibitors, ARBs, calcium channel blockers, and thiazide diuretics (specifically, chlorthalidone, indapamide). Other options in resistant hypertension, after eliminating secondary causes, include mineralocorticoid antagonists, alpha blockers, and centrally acting agents. Evidence supports a BP target of at least less than 140/80 mmHg for all patients with DM, with a more intensive systolic BP target of less than 130 mmHg for those patients who can achieve that target without excessive adverse effects.

ACE inhibitors and angiotensin II receptor blockers (ARBs) are cornerstones of therapy for hypertension in DM because of their favorable effects on diabetic nephropathy and CVD outcomes.,,,

5.

Elsevier ClinicalKey Clinical Overview

Treatment Multifactorial approach to treatment focuses on interventions proven to slow progression of nephropathy as well as preventing associated complications: Main components for all patients with diabetic kidney disease include blood pressure control, strict glycemic control, lifestyle modifications (eg, healthy diet, regular exercise, weight loss if needed), and statin therapy Additional components may include: Renin-angiotensin-aldosterone system blockade for patients with severe albuminuria (in practice, most patients with hypertension are treated with these agents) Kidney-protective therapies (eg, sodium-glucose cotransporter 2 inhibitor, nonsteroidal selective mineralocorticoid receptor antagonist) in patients with type 2 diabetes Treatment of any comorbidities Kidney replacement therapy when needed Blood pressure control: ACE inhibitors (eg, benazepril, captopril, lisinopril, ramipril) or angiotensin receptor blockers (eg, irbesartan, losartan, telmisartan) are preferred first line agents for blood pressure treatment among people with diabetes, hypertension, and diabetic kidney disease For nonpregnant patients with hypertension and diabetes, prescribe either an ACE inhibitor or angiotensin receptor blocker if urinary albumin to creatinine ratio is greater than or equal to 30 mg/g or eGFR is less than 60 mL/minute/1.73 m² Do not combine use of an ACE inhibitor and an angiotensin receptor blocker owing to higher risks of hyperkalemia and acute kidney injury Both drug classes control blood pressure and reduce the risk of progression to end-stage kidney disease in patients with type 1 or type 2 diabetes with diabetic kidney disease (eGFR less than 60 mL/minute/1.73 m² and urinary albumin to creatinine ratio of 300 mg/g or higher)

6.

Food and Drug Administration (DailyMed).

Publish date: March 3, 2024.

Warnings Diabetes and Hypoglycemia Beta-blockers may mask some of the manifestations of hypoglycemia, particularly tachycardia. Nonselective beta-blockers may potentiate insulin-induced hypoglycemia and delay recovery of serum glucose levels. Because of its beta 1 -selectivity, this is less likely with bisoprolol fumarate. However, patients subject to spontaneous hypoglycemia, or diabetic patients receiving insulin or oral hypoglycemic agents, should be cautioned about these possibilities. Also, latent diabetes mellitus may become manifest and diabetic patients given thiazides may require adjustment of their insulin dose. Because of the very low dose of HCTZ employed, this may be less likely with bisoprolol fumarate and hydrochlorothiazide tablets. Thyrotoxicosis Beta-adrenergic blockade may mask clinical signs of hyperthyroidism, such as tachycardia. Abrupt withdrawal of beta-blockade may be followed by an exacerbation of the symptoms of hyperthyroidism or may precipitate thyroid storm. Renal Disease Cumulative effects of the thiazides may develop in patients with impaired renal function. In such patients, thiazides may precipitate azotemia.

7.

Food and Drug Administration (DailyMed).

Publish date: February 1, 2022.

General Precautions Although any chloride deficit is generally mild and usually does not require specific treatment, except under extraordinary circumstances (as in liver disease or renal disease), chloride replacement may be required in the treatment of metabolic alkalosis. Dilutional hyponatremia may occur in edematous patients in hot weather; appropriate therapy is water restriction, rather than administration of salt except in rare instances when the hyponatremia is life threatening. In actual salt depletion, appropriate replacement is the therapy of choice. Hyperuricemia may occur or frank gout may be precipitated in certain patients receiving thiazide therapy. In diabetic patients dosage adjustments of insulin or oral hypoglycemic agents may be required. Hyperglycemia may occur with thiazide diuretics. Thus latent diabetes mellitus may become manifest during thiazide therapy. The antihypertensive effects of the drug may be enhanced in the postsympathectomy patient. If progressive renal impairment becomes evident consider withholding or discontinuing diuretic therapy. Thiazides have been shown to increase the urinary excretion of magnesium; this may result in hypomagnesemia. Thiazides may decrease urinary calcium excretion. Thiazides may cause intermittent and slight elevation of serum calcium in the absence of known disorders of calcium metabolism. Marked hypercalcemia may be evidence of hidden hyperparathyroidism. Thiazides should be discontinued before carrying out tests for parathyroid function. Increases in cholesterol and triglyceride levels may be associated with thiazide diuretic therapy.