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Diabetes mellitus
Hypertension in diabetes
|
Principle: High blood pressure increases the risk of both large and small
blood vessel disease in people with diabetes. Treatment can reduce these risks
by up to 30%.
- High blood pressure should be identified and treated aggressively in
people with diabetes
- Individual blood pressure targets should be set based on the presence or
absence of renal problems in people with diabetes Other vascular risk
factors should also be addressed in people with diabetes and hypertension
(i.e. smoking and lipids)
Procedure
Blood pressure should be measured
- At annual review in everyone with diabetes
- At every appointment in people with hypertension or renal changes
Targets
| Everyone with diabetes |
140/80 |
| Diabetes, aged > 40 with renal changes |
130/75 |
| Diabetes, aged <40 with renal changes |
120 / 70 |
Non drug treatments
- Weight reduction
- Reduced salt intake
- Limitation of alcohol consumption
- Increased physical exercise
- Increased fruit and vegetable consumption
- Reduced total fat and saturated fat intake
The following can reduce associated cardiovascular risk
- Stop smoking Replace saturated fat with polyunsaturated and
monounsaturated fats
- Increase oily fish intake
- Reduce total fat intake
Drug treatment options
| No renal changes |
Bendrofluazide 2.5mg od |
|
| Atenolol 25mg bd |
First line if IHD |
| (No ACE inhibitors (Lisinopril 2.5-40mg
od) |
First line in young or if cardiac
failure is present |
| Calcium antagonists (Amlodipine 5-10mg
od) |
Good in elderly |
| Alpha blockers (Doxazosin) |
Consider if prostatism |
| Renal changes |
ACE inhibitors (Lisinopril 2.5-40mg od)
max tolerated |
Watch U+E's |
| furosemide 20-80mg od |
|
| Calcium antagonists (Amlodipine 5-10mg
od) |
|
| Alpha blockers (Doxazocin) |
|
| Centrally acting drugs (moxonidine,
etc) |
|
Other Points
- One drug will control hypertension in 25% of people with two drugs being
effective in 75%.
- Remember 30% of patients do not take medication as prescribed.
- The risk of renal artery stenosis increases with age, impaired renal
function and evidence of macrovascular disease.
- In patients starting ACE Inhibitors renal function and electrolytes should
be checked after 2 weeks and then every 3-12 months.
A second drug may be more effective and have fewer side effects than
increasing the dose of the first drug.
Useful drug combinations include:
- ACE Inhibitors, Diuretics and Calcium Antagonists.
- Beta Blockers and Calcium Antagonists.
Less useful combinations:
- ACE Inhibitors and Beta Blockers (except where indicated for cardiac
reasons).
- Diuretics and Calcium Antagonists.
Potentially harmful combinations:
- Verapamil or diltiazem with Beta Blockers.
Source: Northumbria NHS Health Care Trust diabetes protocol