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The American Diabetes Association (ADA) has updated the guidelines for hypertension management in diabetes patients. Published in the September issue of Diabetes Care, it is ADA's first updated guidance on the treatment of hypertension since 2003.
The new recommendations provide lifestyle plans to reduce blood pressure (BP), which include suggestions for weight loss, a Dietary Approaches to Stop Hypertension (DASH) style food plan, and increased physical activity. In addition, they point out that the target blood pressure in adult patients with diabetes should be <140/90 mm Hg, once that it reduces cardiovascular events and some microvascular complications.
In patients at high risk of cardiovascular disease, a target lower than 130/80 or 120/80 mm Hg is recommended. However, these goals should be achieved in the least invasive means possible, through lifestyle.
According to the authors, it is necessary for the patient to understand the importance of reducing salt intake, sleeping properly and practicing physical activity. "It will require more time and a nutritionist, but it should be the focus of treatment".
In addition, the report strongly recommends that, in patients with diabetes, blood pressure should be measured at all routine clinical visits. Those with high blood pressure (> 140/90 mm Hg) should have multiple evaluations, on different days, to diagnose hypertension. It should also be encouraged the monitoring of home BP by all hypertensive patients with diabetes, in order to identify the white-coat syndrome.
In addition to lifestyle therapy, treatment for patients with confirmed blood pressure between 140/90 mm Hg and 159/99 mm Hg can be initiated with a single drug. Patients who are at least 20/10 mm Hg above the BP goal should be given single-pill combinations of either renin-angiotensin system [RAS] blockers/calcium-channel blockers or RAS blockers/diuretics. A combination of ACE inhibitors and angiotensin-receptor blockers (ARBs) is not recommended as multidrug therapy to achieve blood-pressure targets.
The authors also emphasize that patients who are pregnant and have preexisting hypertension or mild gestational hypertension (BP <160/105 mm Hg) and no evidence of end-organ damage should not be treated with antihypertensive medications, since there is no benefit that clearly outweighs the potential risks.
Finally, the guideline recommends that individualized treatment must be based on the comorbidities of each patient, and should be part of a shared decision-making process between the clinician and the patient.
de Boer IH, Bangalore S, Benetos A, Davis AM, Michos ED, Muntner P, et al. Diabetes and Hypertension: A Position Statement by the American Diabetes Association. Diabetes Care. 2017; 40(9):1273-1284.