Blood pressure goals and medications for patients with diabetes

This note will discuss blood pressure goals and anti-hypertensive medications which can be used for patients with diabetes.

All pharmacists hear continued debate about how to manage hypertension in patients with diabetes. The recent American College of Cardiology and American Heart Association guidelines recommend a blood pressure goal of less than 130/80 mmHg in patients across the board. Years ago, many of us were also taught this goal for patients with diabetes. But the American Diabetes Association has backed off over the past few years. They now recommend a goal of blood pressure (BP) is less than 140/90 for most diabetes patients or less than 130/80 for diabetes PLUS other cardiovascular risk factors.

These blood pressure goals have been a moving target because the benefits of stricter BP control are less clear-cut in patients with diabetes. For example, a systolic blood pressure goal of less than 120 in diabetes might reduce stroke risk, but not other cardiovascular events or death. Plus reaching a lower goal usually means adding one more antihypertensive medications and increases the risk of hypotension, electrolyte problems, etc.

Individualize BP goals for diabetes patients with hypertension. First, continue to aim for a goal of less than 140/90. There's good evidence this goal improves cardiovascular and renal outcomes in diabetes patients. Then discuss the pros and cons of a lower goal with your patient. Weigh cardiovascular risks, especially a prior (cardiovascular event, kidney disease, etc) with medication side effects, fall risk, life expectancy, etc. Consider a goal of less than 130/80 for those at highest CV risk. For example, suggest a goal of less than 130/80, if tolerated, in a 70-year-old with a prior heart attack who's motivated and adherent.

Continue to recommend an ACEI or ARB first for diabetes patients with hypertension AND albuminuria to slow kidney damage. But for patients without albuminuria, feel comfortable with an ACEI, ARB, thiazide diuretic or dihydropyridine calcium channel blocker first. For example, black patients may get better BP lowering with a thiazide or calcium channel blocker (amlodipine) first, compared to an ACEI or ARB. Emphasize proper home BP monitoring, resting before checking BP, using proper cuff size, etc. Remind patients to track and share results.

References

De Boer, I.H., et al. Individualizing Blood Pressure Targets for People With Diabetes and Hypertension. JAMA, 319(13), p.1319.
Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71(6):1269-1324.
De Boer, I.H., Bangalore, S., Benetos and Bakris, G. (2017). Diabetes and Hypertension: A Position Statement by the American Diabetes Association. Diabetes Care, 40(9), pp.1273–1284.