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Hypertension Management in Diabetic Patients

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Hypertension Management in Diabetic Patients European Review for Medical and Pharmacological Sciences 2011; 15: 1256-1263 Hypertension management in diabetic patients Z. ANWER, P.K. SHARMA, V.K. GARG, N. KUMAR, A. KUMARI Department of Pharmaceutical Technology, Meerut Institute of Engineering and Technology, NH-58, Baghpat By-pass Crossing, Delhi-Haridwar Highway, Meerut (India) Abstract. – Hypertension and diabetes are Stage two hypertension: consistent readings of becoming increasingly common. Clinical trials 160/100 mmHg or higher. have demonstrated the importance of tight Pre-hypertension: consistent readings of 120- blood pressure control among patients with dia- betes. However, little is known regarding the 139/80-89 mmHg. management of hypertension in patients with coexisting diabetes. Most patients with both dis- Diabetes mellitus often simply referred to as orders have a markedly worsened risk for pre- diabetes is a condition in which a person has a mature micro vascular and macro vascular com- high blood sugar level, either because the body plications. The appropriate management of the doesn’t produce enough insulin, or because body hypertension seen in almost 70% of patients cells don’t properly respond to the insulin that is with type 2 diabetes mellitus remains controver- 3 sial. However, over the past few years, many ran- produced . There are many types of diabetes, the 4 domized, controlled trials have provided guid- most common of which are : ance for more effective therapy. These trials have established the need for a lower goal blood Type 1 diabetes: results from the body’s failure pressure (<130/80 mm Hg) than has previously to produce insulin, and presently requires the been recommended. To achieve therapy goals, person to inject insulin. multiple antihypertensive drugs are usually needed. Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin Key Words: properly, sometimes combined with an ab- solute insulin deficiency. Hypertension, Diabetes mellitus, Macrovascular, Mi- Gestational diabetes: it is when pregnant women, crovascular, Cardiovascular disease. who have never had diabetes before and have high blood glucose level during pregnancy. It may precede development of type 2 diabetes mellitus. Introduction Other forms of diabetes mellitus include con- genital diabetes, which is due to genetic defects Hypertension (defined as a blood pressure of insulin secretion, cystic fibrosis-related dia- ≥140/90 mmHg) is an extremely common condi- betes, steroid diabetes induced by high doses of tion in diabetes, affecting ∼20-60% of patients gluco-corticoids, and several forms of monogenic with diabetes, depending on obesity, ethnicity, diabetes. and age. Hypertension is a condition in which blood pressure is high. It can be caused by genet- ics, diet as well as stress. It is associated with How are Diabetes and significant health problems such as stroke and Hypertension Related? heart attack1,2. The following clinical levels of hypertension1,2 have been described by The Na- Diabetes and high blood pressure tend to occur tional Heart, Lung, and Blood Institute: together because they share certain physiological traits. High blood pressure is a dangerous disease Stage one hypertension: consistent (i.e., two or that becomes even more problematic in the setting more consecutive) readings of 140-159/90-99 of diabetes. Unfortunately, many people with dia- mmHg. betes are also affected by high blood pressure, and 1256 Corresponding Author: Zaihra Anwer, MD; [email protected] Hypertension management in diabetic patients the two diseases commonly occur together5-7. Dia- The well-studied example of the self-reinforcing betes and high blood pressure occur together so relationship between diabetes and high blood pres- frequently that they are officially considered to be sure takes place in the kidneys. The kidneys are the “comorbidities” (diseases likely to be present in the body’s most important long-term blood pressure same patient). In the case of diabetes and high regulator. By balancing the amount of salt and blood pressure, these effects include: potassium in the body, the kidneys ultimately con- trol how much fluid is excreted as urine. This fluid Increased Fluid Volume – Diabetes increases regulating function helps to modulate long-term the total amount of fluid in the body, which blood pressure by physically controlling how much tends to raise blood pressure. liquid is present in the blood vessels. Increased Arterial Stiffness – Diabetes can de- crease the ability of the blood vessels to stretch, increasing average blood pressure. Relationship Between Diabetes Impaired Insulin Handling – Changes in the and Hypertension way the body produces and handles insulin can directly cause increases in blood pressure. Figure 1 shows the interrelationship between the hyperglycemia and the hypertension through Apart from above factors the two diseases are the intervention of insulin resistance, a common likely to occur together simply because they link between the two diseases. share a common set of risk factors. Some impor- tant shared risk factors are: Statistical Relationship Individuals with diabetes are at a much greater Body Mass – Being overweight significantly in- risk for developing. Hypertension is twice as creases the risk of both diabetes and high common in those with diabetes as in non diabetic blood pressure. individuals1,2,8. Diet – High fat diets rich in salt and processed sugars are known to contribute to the develop- Physical Relationship ment of organ problems that can lead to both Diabetes causes hyperinsulinemia and raises diabetes and high blood pressure. the risk of hypertension. This condition increases Activity Level – A low level of physical activity the amount of sodium that the body absorbs. It makes insulin less effective (which can lead to also promotes the stimulation of the sympathetic diabetes) and can contribute to the develop- nervous system. This is thought to cause changes ment of stiff blood vessels, increasing the risk in blood vessel structure, which affects the func- of high blood pressure. tion of the heart and blood pressure1,2,8. Figure 1. Metabolic syndrome. 1257 Z. Anwer, P.K. Sharma, V.K. Garg, N. Kumar, A. Kumari Obesity Guidelines for the Management Metabolism is related to obesity, which is re- of Hypertension lated to diabetes, which is related to hyperten- sion. Reducing in weight can often lower blood Effective blood pressure control is an impor- pressure. This lowering of hypertension symp- tant goal for diabetic patients. The patients who toms is associated with a decrease in the symp- suffer from both diabetes and hypertension have toms of diabetes1,2,8. greater chances of developing cardiovascular dis- order10. The following guidelines must be consid- ered for the management of hypertension in dia- Evidences betic patients: Hypertension as a Risk Factor for Measurement of Arterial Blood Pressure: The Complications of Diabetes object of identifying and treating high blood Diabetes increases the risk of coronary events pressure is to reduce the risk of cardiovascular two fold in men and four fold in women. This in- disorder and associated morbidity and mortali- crease is due to the frequency of associated car- ty. It is, therefore, necessary to provide a clas- diovascular risk factors such as hypertension, sification of blood pressure in adults so as to dyslipidemia and clotting abnormalities. People identify the high risk individuals and to pro- with both diabetes and hypertension have ap- vide guidelines for treatment and follow up. proximately twice the risk of cardiovascular dis- Arterial blood pressure measured in the sitting ease as non-diabetic people with hypertension. position should be considered as ideal11. Hypertensive diabetic patients are also at in- Systolic and Diastolic Pressure Target Values: creased risk for diabetes-specific complications The level to which blood pressure should be including retinopathy and nephropathy1,2. reduced in a diabetic hypertensive patient has not been known12. There are no specific guide- Evidence for Target Levels of lines on the exact values for hypertension con- Blood Pressure in Patients with Diabetes trol in diabetes. A number of epidemiological The UK Prospective Diabetes Studies studies suggest an inverse relationship exist (UKPDS) and the Hypertension Optimal Treat- between calcium, magnesium, potassium in- ment (HOT) trial both demonstrated improved take and blood pressure level13-15. Most of outcomes, especially in preventing stroke, in pa- these studies are cross-sectional, but none of tients assigned to lower blood pressure targets. these studies has analyzed diabetic patients Optimal outcomes in the HOT study were separately from the general hypertension pop- achieved in the group with a target diastolic ulation. There are no randomized clinical trials blood pressure of 80 mmHg. Randomized clini- on magnesium supplementation in diabetic cal trials demonstrate the benefit of targeting a subjects with hypertension. diastolic blood pressure of ≤80 mmHg. Epi- Screening and Initial Evaluation: All patients demiological analyses show that blood pres- with diabetes should have blood pressure mea- sures ≥120/70 mmHg are associated with in- sured at the time of diagnosis and at each creased cardiovascular event rates and mortality scheduled diabetes visit13. Initial assessment of in persons with diabetes. Therefore, a target a hypertensive diabetic patient should include blood pressure goal of <130/80 mmHg is rea- a complete
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