Managing Hypertension in Patients With Type 2 Diabetes Mellitus

Paul P. Dobesh

Disclosures

Am J Health Syst Pharm. 2006;63(12):1140-1149. 

In This Article

Abstract and Introduction

Purpose: Current guideline recommendations for effective strategies to optimize the treatment of patients with concomitant hypertension and type 2 diabetes mellitus are reviewed.
Summary: Current estimates indicate that 20 million people in the United States have diabetes, 90-95% of whom have type 2 diabetes mellitus. Type 2 diabetes mellitus is associated with an increased risk of premature death from cardiovascular disease (CVD), stroke, and end-stage renal disease. Hypertension is an extremely common comorbidity in patients with type 2 diabetes mellitus. The coexistence of hypertension in patients with type 2 diabetes is particularly destructive because of the strong linkage of the two conditions with CVD, stroke, progression of renal disease, and diabetic nephropathy. Current guidelines, including those issued by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, the National Kidney Foundation, and the American Diabetes Association, provide evidence-based recommendations for the treatment of hypertension in patients with type 2 diabetes mellitus. However, studies indicate that guidelines are not widely followed. Therefore, the beneficial effects of appropriate hypertension treatment observed in clinical trials are often not recognized in clinical practice. Pharmacists are ideally positioned to help improve guideline implementation and patient outcome.
Conclusion: Pharmacists must become more vigilant about following current guidelines for the treatment of patients with concomitant hypertension and type 2 diabetes mellitus. Strategies such as patient education and medication assessment can help to optimize care for these patients and slow the progression to diabetic nephropathy.

Current estimates indicate that 20 million people in the United States have diabetes, 90-95% of whom have type 2 diabetes mellitus.[1] The number of Americans with diabetes is projected to increase dramatically in forthcoming years due to increasing rates of obesity, lack of physical activity, and an aging population.[2] Patients with diabetes have an increased risk of developing a wide range of disease-related complications, both macrovascular (e.g., cardiovascular disease [CVD]) and microvascular (e.g., nephropathy, retinopathy, and neuropathy).

CVD is the leading cause of death among patients with diabetes,[2,3,4] with between two thirds and three fourths dying of some form of CVD.[1] Diabetes-related heart disease represents the largest CVD burden among this population and is characterized by a propensity to develop premature or diffuse atherosclerotic disease, structural and functional abnormalities of the microvasculature, autonomic dysfunction, and intrinsic myocardial dysfunction.[3]

Diabetes is also associated with an increased frequency of renal disease ( Table 1 ).[5] About 20-30% of patients with type 1 or type 2 diabetes mellitus develop nephropathy. If nephropathy is ineffectively controlled, renal function will progressively decline, resulting in end-stage renal disease (ESRD).[5] Estimates indicate that 2.0% of patients with type 2 diabetes mellitus per year develop microalbuminuria, 2.8% per year progress from microalbuminuria to macroalbuminuria, and 2.3% per year progress from macroalbuminuria to elevated plasma creatinine concentrations (≥175 µmol/L [≥2.0 mg/dL]) or hemodialysis.[6] Diabetic nephropathy is the leading cause of ESRD in Western countries, particularly in patients with type 2 diabetes mellitus.[7] Recent statistics from the National Institutes of Health indicate that diabetes is the cause of ESRD in 53% of patients in the United States and that patients with diabetes account for 45% of patients with ESRD.[8] In addition to the risk of progression to ESRD, diabetic nephropathy is associated with a substantially increased risk of cardiovascular morbidity and mortality that is not ameliorated by hemodialysis or renal transplantation.[7,9,10,11]

Hypertension is an extremely common comorbidity in patients with diabetes, affecting approximately 20-60% of patients, depending on age, ethnicity, and body weight.[12] The development of hypertension in patients with diabetes is particularly harmful, as it accelerates the development of CVD and is estimated to be responsible for up to 75% of diabetic cardiovascular complications, including stroke, coronary artery disease, and peripheral vascular disease.[13,14,15,16] Hypertension is also thought to play a major etiologic role in the development of retinopathy, nephropathy, and possibly neuropathy.[4,14,17,18]

Randomized clinical trials have demonstrated the benefit (i.e., reduction in CVD, stroke, or nephropathy events) of lowering blood pressure in individuals with diabetes.[14,19,20,21] Despite the availability of national and international guidelines, hypertension detection and control in this population are inadequate.[22] This article reviews the current guidelines, best practices, and recommendations for the treatment of hypertension in patients with type 2 diabetes mellitus.

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