Diabetes with hypertension medical therapy: Difference between revisions

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__NOTOC__
{{Diabetes mellitus }}
{{Diabetes mellitus }}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh@perfuse.org]; {{CZ}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Priyamvada Singh|Priyamvada Singh, M.B.B.S.]] [mailto:psingh13579@gmail.com]; {{CZ}}


==Overview==
==Overview==
Hypertension is a common co-morbidity associated with patients of diabetes, especially type 2 diabetes. Proper management of both these conditions are important to prevent future chronic complications like cardiovascular, nephrology and other complications.
[[Hypertension]] is a common co-morbidity associated with patients of [[diabetes]], especially type 2 diabetes. Co-existence of these conditions strongly predispose patients to both [[renal]] as well as [[cardiovascular]] (CV) injury.  Diabetes is the most common cause of [[end-stage renal disease]] in the United States. The 1994 Working Group Report on Hypertension and Diabetes, has recommended the original blood pressure goals of less than 130/85 mmHg to preserve renal function and reduce cardiovascular events in these groups of patients.


==Supportive trial data==
==Treatment==
The preferred treatment of the diabetic with hypertension includes:
:*[[ACE inhibitors]] which may provide benefits above and beyond control of hypertension including delaying progression of renal disease.
:*[[Calcium channel blockers]]
:*Low dose [[diuretics]]


===Study name:LIFE study, 2002<ref name="pmid11937179">{{cite journal| author=Lindholm LH, Ibsen H, Dahlöf B, Devereux RB, Beevers G, de Faire U et al.| title=Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. | journal=Lancet | year= 2002 | volume= 359 | issue= 9311 | pages= 1004-10 | pmid=11937179 | doi=10.1016/S0140-6736(02)08090-X | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11937179  }}  [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12418827 Review in: ACP J Club. 2002 Nov-Dec;137(3):87] </ref>===
==Supportive Trial Data==
* Study design: Double blind, randomised, parallel-group trial
* Sample size: 1195 patients with diabetes, hypertension, left-ventricular hypertrophy on electrocardiograms
* Drugs: Losartan or Atenolol
* Study period: 4 years
* Study results: Losartan was found to be more effective than atenolol in reducing composite endpoints like cardiovascular morbidity and all causes mortality in patients with hypertension, diabetes, and left-ventricular hypertrophy.


===Study name: Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial, ('''[[FACET]]'''), 1998 <ref name="pmid9571349">{{cite journal| author=Tatti P, Pahor M, Byington RP, Di Mauro P, Guarisco R, Strollo G et al.| title=Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. | journal=Diabetes Care | year= 1998 | volume= 21 | issue= 4 | pages= 597-603 | pmid=9571349 | doi= | pmc= | url= }} </ref>===
===Study Name: LIFE Study, 2002 <ref name="pmid11937179">{{cite journal| author=Lindholm LH, Ibsen H, Dahlöf B, Devereux RB, Beevers G, de Faire U et al.| title=Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. | journal=Lancet | year= 2002 | volume= 359 | issue= 9311 | pages= 1004-10 | pmid=11937179 | doi=10.1016/S0140-6736(02)08090-X | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11937179  }} [http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12418827 Review in: ACP J Club. 2002 Nov-Dec;137(3):87] </ref>===
* Study design: Open label, randomized trial
* '''Study design''': Double blinded, randomised, parallel-group trial
* Sample size: 380 [[hypertension|hypertensive]] diabetics patient
* '''Sample size''': 1195 patients with diabetes, hypertension, [[left ventricular hypertrophy]] (on electrocardiograms)
* Drugs: [[Fosinopril]] (20 mg/day) or [[amlodipine]] (10 mg/day)
* '''Study drugs''': [[Losartan]] or [[Atenolol]]
* Study period: 3.5 years
* '''Study period''': 4 years  
* Inclusion criteria- [[NIDDM]] and hypertension (SBP > 140 mmHg or DBP > 90 mmHg).
* '''Study results''': Losartan was found to be more effective than atenolol in reducing composite endpoints like cardiovascular morbidity and all causes mortality in patients with hypertension, diabetes, and [[left-ventricular hypertrophy]].
* Exclusion criteria- History of [[coronary heart disease]] or [[stroke]], serum [[creatinine]] > 1.5 mg/dl, [[albuminuria]] > 40 micrograms/min, and use of lipid-lowering drugs, [[aspirin]], or antihypertensive agents other than [[beta-blocker]]s or [[diuretic]]s.
* Study results: Fosinopril lowered the risk of the composite endpoints of acute [[myocardial infarction]], stroke, or hospitalization due to [[angina]] more compared to amlodipine (hazards ratio = 0.49, 95% CI = 0.26-0.95). However, no significant difference in total [[serum cholesterol]], [[HDL cholesterol]], [[HbA1c]], fasting serum glucose, or plasma insulin was found.


===Study Name: Candesartan and Lisinopril Microalbuminuria (CALM) Study, 2000 <ref name="pmid11110735">{{cite journal| author=Mogensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW et al.| title=Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study. | journal=BMJ | year= 2000 | volume= 321 | issue= 7274 | pages= 1440-4 | pmid=11110735 | doi= | pmc=PMC27545 | url= }} </ref>===
* '''Study design''': Double blinded,  prospective, randomised, parallel-group, multicenteric (4 countries, 37 centers) trial
* '''Sample size''': 199 patients with diabetes & hypertension
* '''Study drugs''': [[Candesartan]] or [[lisinopril]]
* '''Study period''':
** Placebo run in period-4 weeks
** 12 weeks Candesartan or lisinopril
** Followed by 12 weeks' monotherapy or combination treatment
* '''Study question''': Compare the effects of candesartan or lisinopril, or both, on blood pressure and urinary albumin excretion , hypertension, and type 2 diabetes.
* '''Study results''':  Candesartan was found to be as effective as lisinopril in reducing blood pressure and [[microalbuminuria]] in hypertensive type 2 diabetics. Combination treatment (Candesartan+lisinopril) was well tolerated and more effective in reducing blood pressure compared to either drugs alone.
===Study Name: Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial, ([[FACET]]), 1998 <ref name="pmid9571349">{{cite journal| author=Tatti P, Pahor M, Byington RP, Di Mauro P, Guarisco R, Strollo G et al.| title=Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. | journal=Diabetes Care | year= 1998 | volume= 21 | issue= 4 | pages= 597-603 | pmid=9571349 | doi= | pmc= | url= }} </ref>===
* '''Study design''': Open label, randomized trial
* '''Sample size''': 380 [[hypertension|hypertensive]] diabetics patient
* '''Study drugs''': [[Fosinopril]] (20 mg/day) or [[amlodipine]] (10 mg/day)
* '''Study period''': 3.5 years
* '''Inclusion criteria'''- [[NIDDM]] and hypertension (SBP > 140 mmHg or DBP > 90 mmHg).
* '''Exclusion criteria'''- History of [[coronary heart disease]] or [[stroke]], serum [[creatinine]] > 1.5 mg/dl, [[albuminuria]] > 40 micrograms/min, and use of lipid-lowering drugs, [[aspirin]], or antihypertensive agents other than [[beta-blocker]]s or [[diuretic]]s.
* '''Study results''': Fosinopril lowered the risk of the composite endpoints of acute [[myocardial infarction]], stroke, or hospitalization due to [[angina]] more compared to amlodipine (hazards ratio = 0.49, 95% CI = 0.26-0.95). However, no significant difference in total [[serum cholesterol]], [[HDL cholesterol]], [[HbA1c]], fasting serum glucose, or plasma insulin was found.
===Hypertension/ Blood Pressure Control===
{|class="wikitable"
| bgcolor="Seashell"|<nowiki>"</nowiki>'''1.''' '''Screening and diagnosis:''' Blood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="Seashell"|<nowiki>"</nowiki>'''2.''' '''Goals:'''
*People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
*Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg.. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="Seashell"|<nowiki>"</nowiki>'''3.''' '''Treatment:'''
*Patients with a blood pressure <120/ 80 mmHg should be advised on life- style changes to reduce blood pressure. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*Patients with confirmed blood pressure ≥140/80 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight; Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*Pharmacological therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker (ARB). If one class is not tolerated, the other should be substituted. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
*Multiple-drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
*Administer one or more antihypertensive medications at bedtime. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
*If ACE inhibitors, ARBs, or diuretics are used, serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: E]])''<nowiki>"</nowiki>
*In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110–129/65–79 mmHg are suggested in the interest of long- term maternal health and minimizing impaired fetal growth. ACE inhibitors and ARBs are contraindicated during pregnancy. ''([[ADA guidelines classification scheme#Level of Evidence|Level of Evidence: E]])''<nowiki>"</nowiki>
|-
|}
==References==
==References==
{{reflist|2}}
{{reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 21:20, 29 July 2020

Diabetes mellitus Main page

Patient Information

Type 1
Type 2

Overview

Classification

Diabetes mellitus type 1
Diabetes mellitus type 2
Gestational diabetes

Differential Diagnosis

Complications

Screening

Diagnosis

Prevention

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]; Cafer Zorkun, M.D., Ph.D. [3]

Overview

Hypertension is a common co-morbidity associated with patients of diabetes, especially type 2 diabetes. Co-existence of these conditions strongly predispose patients to both renal as well as cardiovascular (CV) injury. Diabetes is the most common cause of end-stage renal disease in the United States. The 1994 Working Group Report on Hypertension and Diabetes, has recommended the original blood pressure goals of less than 130/85 mmHg to preserve renal function and reduce cardiovascular events in these groups of patients.

Treatment

The preferred treatment of the diabetic with hypertension includes:

Supportive Trial Data

Study Name: LIFE Study, 2002 [1]

  • Study design: Double blinded, randomised, parallel-group trial
  • Sample size: 1195 patients with diabetes, hypertension, left ventricular hypertrophy (on electrocardiograms)
  • Study drugs: Losartan or Atenolol
  • Study period: 4 years
  • Study results: Losartan was found to be more effective than atenolol in reducing composite endpoints like cardiovascular morbidity and all causes mortality in patients with hypertension, diabetes, and left-ventricular hypertrophy.

Study Name: Candesartan and Lisinopril Microalbuminuria (CALM) Study, 2000 [2]

  • Study design: Double blinded, prospective, randomised, parallel-group, multicenteric (4 countries, 37 centers) trial
  • Sample size: 199 patients with diabetes & hypertension
  • Study drugs: Candesartan or lisinopril
  • Study period:
    • Placebo run in period-4 weeks
    • 12 weeks Candesartan or lisinopril
    • Followed by 12 weeks' monotherapy or combination treatment
  • Study question: Compare the effects of candesartan or lisinopril, or both, on blood pressure and urinary albumin excretion , hypertension, and type 2 diabetes.
  • Study results: Candesartan was found to be as effective as lisinopril in reducing blood pressure and microalbuminuria in hypertensive type 2 diabetics. Combination treatment (Candesartan+lisinopril) was well tolerated and more effective in reducing blood pressure compared to either drugs alone.

Study Name: Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial, (FACET), 1998 [3]

Hypertension/ Blood Pressure Control

"1. Screening and diagnosis: Blood pressure should be measured at every routine visit. Patients found to have elevated blood pressure should have blood pressure confirmed on a separate day. (Level of Evidence: B)"
"2. Goals:
  • People with diabetes and hypertension should be treated to a systolic blood pressure goal of <140 mmHg. (Level of Evidence: B)"
  • Lower systolic targets, such as <130 mmHg, may be appropriate for certain individuals, such as younger patients, if it can be achieved without undue treatment burden. (Level of Evidence: C)"
  • Patients with diabetes should be treated to a diastolic blood pressure <80 mmHg.. (Level of Evidence: B)"
"3. Treatment:
  • Patients with a blood pressure <120/ 80 mmHg should be advised on life- style changes to reduce blood pressure. (Level of Evidence: B)"
  • Patients with confirmed blood pressure ≥140/80 mmHg should, in addition to lifestyle therapy, have prompt initiation and timely subsequent titration of pharmacological therapy to achieve blood pressure goals. (Level of Evidence: B)"
  • Lifestyle therapy for elevated blood pressure consists of weight loss, if overweight; Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern including reducing sodium and increasing potassium intake; moderation of alcohol intake; and increased physical activity. (Level of Evidence: B)"
  • Pharmacological therapy for patients with diabetes and hypertension should be with a regimen that includes either an ACE inhibitor or an angiotensin receptor blocker (ARB). If one class is not tolerated, the other should be substituted. (Level of Evidence: C)"
  • Multiple-drug therapy (two or more agents at maximal doses) is generally required to achieve blood pressure targets. (Level of Evidence: B)"
  • Administer one or more antihypertensive medications at bedtime. (Level of Evidence: A)"
  • If ACE inhibitors, ARBs, or diuretics are used, serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored. (Level of Evidence: E)"
  • In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110–129/65–79 mmHg are suggested in the interest of long- term maternal health and minimizing impaired fetal growth. ACE inhibitors and ARBs are contraindicated during pregnancy. (Level of Evidence: E)"

References

  1. Lindholm LH, Ibsen H, Dahlöf B, Devereux RB, Beevers G, de Faire U; et al. (2002). "Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention For Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol". Lancet. 359 (9311): 1004–10. doi:10.1016/S0140-6736(02)08090-X. PMID 11937179. Review in: ACP J Club. 2002 Nov-Dec;137(3):87
  2. Mogensen CE, Neldam S, Tikkanen I, Oren S, Viskoper R, Watts RW; et al. (2000). "Randomised controlled trial of dual blockade of renin-angiotensin system in patients with hypertension, microalbuminuria, and non-insulin dependent diabetes: the candesartan and lisinopril microalbuminuria (CALM) study". BMJ. 321 (7274): 1440–4. PMC 27545. PMID 11110735.
  3. Tatti P, Pahor M, Byington RP, Di Mauro P, Guarisco R, Strollo G; et al. (1998). "Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM". Diabetes Care. 21 (4): 597–603. PMID 9571349.

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