L.N. is a 49-year-old white woman with a history of type 2 diabetes, obesity, hypertension, and migraine headaches. The patient was diagnosed with type 2 diabetes 9 years ago when she presented with mild polyuria and polydipsia. L.N. is 5′4″ and has always been on the large side, with her weight fluctuating between 165 and 185 lb. Initial treatment for her diabetes consisted of an oral sulfonylurea with the rapid addition of metformin. Her diabetes has been under fair control with a most recent hemoglobin A1c of 7.4%. Hypertension was diagnosed 5 years ago when blood pressure (BP) measured in the office was noted to be consistently elevated in the range of 160/90 mmHg on three occasions. L.N. was initially treated with lisinopril, starting at 10 mg daily and increasing to 20 mg daily, yet her BP control has fluctuated. One year ago, microalbuminuria was detected on an annual urine screen, with 1,943 mg/dl of microalbumin identified on a spot urine sample. L.N. comes into the office today for her usual follow-up visit for diabetes. Physical examination reveals an obese woman with a BP of 154/86 mmHg and a pulse of 78 bpm. Questions What are the effects of controlling BP in people with diabetes? What is the target BP for patients with diabetes and hypertension? Which antihypertensive agents are recommended for patients with diabetes?

Controlling blood pressure (BP) in individuals with diabetes is crucial in preventing and managing complications of the disease. Elevated BP, commonly referred to as hypertension, is a common comorbidity in people with diabetes and is associated with an increased risk of cardiovascular disease (CVD), stroke, and kidney disease.

The effects of controlling BP in people with diabetes are multifaceted and encompass both short-term and long-term outcomes. In the short-term, maintaining optimal BP levels can help alleviate symptoms such as headache, dizziness, and fatigue. It can also mitigate the risk of acute complications such as heart attack and stroke, which can have a significant impact on morbidity and mortality.

Long-term effects of controlling BP include preventing or slowing the progression of diabetes-related complications. High BP can damage blood vessels throughout the body, leading to atherosclerosis, narrowing of arteries, and reduced blood flow to vital organs. In people with diabetes, this can manifest as diabetic nephropathy (kidney disease), retinopathy (eye disease), and peripheral arterial disease. By controlling BP, the risk of developing or worsening these complications can be reduced.

The target BP for patients with diabetes and hypertension is generally lower than that for individuals without diabetes. The American Diabetes Association (ADA) recommends a target BP of <140/90 mmHg for most adults with diabetes. However, in certain patient populations, such as those with existing kidney disease or albuminuria (as in the case of L.N.), a lower target of <130/80 mmHg may be appropriate. It is important to individualize treatment goals based on patient characteristics and comorbidities. To achieve and maintain target BP levels, a combination of lifestyle modifications and medication therapy is often necessary. Lifestyle modifications include dietary changes (such as reducing sodium intake), regular physical activity, weight loss, and smoking cessation. These lifestyle interventions can help lower BP and improve overall cardiovascular health. In terms of antihypertensive agents recommended for patients with diabetes, several classes of medications have shown efficacy in managing BP. The ADA and other guidelines recommend using antihypertensive medications from specific drug classes that have demonstrated cardiovascular benefit in patients with diabetes. These include angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), which have renoprotective effects and are considered first-line agents in patients with diabetes and hypertension. Examples of ACEIs include lisinopril, which L.N. is currently taking, and ARBs such as losartan or valsartan. Other recommended antihypertensive agents for patients with diabetes include thiazide diuretics (such as hydrochlorothiazide), calcium channel blockers (CCBs), and, in some cases, beta-blockers. Thiazide diuretics are often used as initial therapy in patients without contraindications, as they are cost-effective and have been shown to reduce cardiovascular events. CCBs, such as amlodipine or diltiazem, can be used as monotherapy or in combination with other agents. Beta-blockers, such as metoprolol or atenolol, may be considered in specific situations, such as concurrent heart disease or post-myocardial infarction. In conclusion, controlling BP is crucial in individuals with diabetes to prevent and manage complications. The target BP for patients with diabetes and hypertension is generally <140/90 mmHg, with lower targets (<130/80 mmHg) in certain patient populations. Lifestyle modifications and medication therapy, including ACEIs, ARBs, thiazide diuretics, CCBs, and, in some cases, beta-blockers, are recommended to achieve and maintain optimal BP levels. Individualized treatment goals should be based on patient characteristics and comorbidities.