What are the ADA recommendations for the control of hypertension (high blood pressure)?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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Answer

In its 2016 Standards of Medical Care in Diabetes, the ADA makes the following recommendations for the control of high blood pressure  [71] :

  • Initiation of pharmacotherapy is recommended for all diabetic patients with confirmed office-based blood pressure >140/90 mm Hg
  • Treat with a regimen that includes either an ACEI or an ARB; if one class is not tolerated, the other can be substituted
  • Multiple-drug therapy (including a thiazide diuretic and ACEI/ARB, at maximal doses) is generally required to achieve blood pressure targets
  • Serum creatinine/estimated glomerular filtration rate (eGFR) and serum potassium levels should be monitored in patients receiving ACEIs, ARBs, or diuretics

2017 ADA guidelines

The ADA released updated guidelines for patients with hypertension and diabetes in 2017, as follows [83] :

Blood pressure should be measured at every routine clinical care visit. Patients found to have an elevated blood pressure (≥140/90 mm Hg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension.

All hypertensive patients with diabetes should have home blood pressure monitored to identify white coat hypertension.

Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed.

Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of < 140 mm Hg and a diastolic blood pressure goal of < 90 mm Hg.

Lower systolic and diastolic blood pressure targets, such as < 130/80 mm Hg, may be appropriate for individuals at high risk of cardiovascular disease if they can be achieved without undue treatment burden.

For patients with systolic blood pressure >120 mm Hg or diastolic blood pressure >80 mm Hg, lifestyle intervention consists of weight loss if overweight or obese; a Dietary Approaches to Stop Hypertension (DASH)-style dietary pattern, including reduced sodium and increased potassium intake; increased fruit and vegetable consumption; moderation of alcohol intake; and increased physical activity.

Patients with confirmed office-based blood pressure ≥140/90 mm Hg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals.

Patients with confirmed office-based blood pressure ≥160/100 mm Hg should, in addition to lifestyle therapy, have prompt initiation and timely titration of 2 drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes.

Treatment for hypertension should include drug classes demonstrated to reduce cardiovascular events in patients with diabetes: ACEIs, ARBs, thiazide-like diuretics, or dihydropyridine calcium channel blockers. Multiple-drug therapy is generally required to achieve blood pressure targets (but not a combination of ACEIs and ARBs).

An ACEI or ARB, at the maximum tolerated dose indicated for blood pressure treatment, is the recommended first-line treatment for hypertension in patients with diabetes and urine albumin-to-creatinine ratio ≥300 mg/g creatinine or 30–299 mg/g creatinine. If one class is not tolerated, the other should be substituted.

For patients treated with an ACEI, ARB, or diuretic, serum creatinine/estimated glomerular filtration rate and serum potassium levels should be monitored.

Pregnant women with diabetes and preexisting hypertension or mild gestational hypertension with systolic blood pressure < 160 mm Hg, diastolic blood pressure < 105 mm Hg, and no evidence of end-organ damage do not need to be treated with pharmacologic antihypertensive therapy.

In pregnant patients with diabetes and preexisting hypertension who are treated with antihypertensive therapy, systolic or diastolic blood pressure targets of 120–160/80–105 mm Hg are suggested in the interest of optimizing long-term maternal health and fetal growth.


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