2.11 Blood Pressure Control at the Diabetes Planned Visit

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.

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):

BB first if S/P MI, CABG or angioplasty.
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.

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.

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)

Diabetes Planned Visit Notebook