With George L. Bakris, MD, Priyathama Vellanki, MD, and Mark E. Molitch, MD
For the first time in nearly 15 years, the American Diabetes Association (ADA) has updated its position statement on the screening and diagnosis of hypertension in patients with diabetes.1 The update to the existing guideline is of vital importance given that patients with diabetes often develop hypertension, and it is a strong risk factor for cardiovascular disease, heart failure, and microvascular complications.
The position statement is authored by nine leading diabetes experts on behalf of the ADA, including George L. Bakris, MD, professor of medicine and director of the ASH Comprehensive Hypertension Center at the University of Chicago Medicine. Dr. Bakris spoke with EndocrineWeb to offer his insight on key changes to the guidelines of particular interest to clinicians. The position statement was made available August 22 online and is scheduled to be published in the September 2017 issue of Diabetes Care.1
"In terms of blood pressure goals, we did it in two tiers," Dr. Bakris told EndocrineWeb. "We said everyone should be below 140 over 90, regardless.'' Blood pressure should also be measured at every routine clinical care visit.
Furthermore, Dr. Bakris said there is an indication for reducing blood pressure below 130/80. "Most people should be urged to go to 130/80 [or below] because the cardiovascular risk in that subgroup of people is higher than the general population," he stated. "The level of evidence is not as strong, but it's reasonable." He cited the findings from the Action to Control Cardiovascular Risk In Diabetes (ACCORD) blood pressure trial (ACCORD BP), among others, supporting the lower target.
In the ACCORD BP trial, intensive blood pressure control (below 120 mmHg), compared to blood pressures below 140 mmHg, resulted in no significant differences in the composite outcome of myocardial infarction, stroke or cardiovascular death, but did reduce stroke by 41%. However, serious adverse events linked to the antihypertensive therapy increased in the intensive group.
In the statement, the authors said the lower targets ''may be appropriate for individuals at high risk of cardiovascular disease if [these targets] can be achieved without undue treatment burden."
How does Dr. Bakris encourage his patients to aim for the lower target? He uses the Atherosclerotic Cardiovascular Disease (ASCVD) Risk Estimator app made available by both the American College of Cardiology (ACC) and the American Heart Association (AHA) for estimating 10-year and lifetime risks for developing cardiovascular disease (CVD). Seeing a patient’s risk of death from CVD is motivating, Dr. Bakris stated.
Six areas of clinical concern from the position paper are highlighted :
For patients with blood pressures between 140/90 mmHg and below 160/100, the guideline suggests starting with one medication. Medication choice may be dependent on the presence of albumin in urine, a potential indication of kidney disease. If albuminuria is included, angiotensin-converting-enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers (ARBs) may be considered better choices. If albuminuria is excluded, prescription drugs to treat hypertension may include ACE inhibitors, ARBs, calcium channel blockers (CCBs), or a type of diuretic.
Patients with initial blood pressures 160/100 mmHg or higher, the statement suggests starting therapy with two agents. If albuminuria is not present, medication choices include ACE inhibitors or ARBs, CCBs or a diuretic. If albuminuria is detected, the position statement suggests either an ACE inhibitor or ARB with either a CCB or diuretic.
Lifestyle changes are encouraged in patients with blood pressures above 120/80. This includes weight loss if necessary, following the Dietary Approaches to Stop Hypertension, or DASH-style dietary pattern combined with increased physical activity as tolerated.
"We have strongly urged, with very solid data, the use of home blood pressure monitoring for all patients [on anti-hypertensive medicines]," Dr. Bakris said. He suggests patients measure their blood pressure first thing in the morning before taking blood pressure medicines. “It's not vital to do it every day,” he said, but ideally patients should measure their blood pressure two or three times a week until their pressure is stabilized, then weekly thereafter.
Under the new statement, "it's no longer mandatory to use an ACE or ARB as initial therapy in the treatment of hypertension in someone with diabetes if they have less than 300 mg a day of albumin," Dr. Bakris says. "You can use different drugs." He added, “Putting ACE inhibitors in the drinking water is not going to protect our kidneys.”
"We talk about tolerability and we make a couple of points," Dr. Bakris said. "In older people [above age 65] you [clinicians] should start at a lower dose and titrate up slowly," he stated. "Physician inertia is a major problem with failing to meet blood pressure goals," he told EndocrineWeb. Closer follow-up can help solve this, he told EndocrineWeb.
The position statement included pregnant women with diabetes who have pre-existing or mild gestational hypertension. Patients with systolic pressures below 160 mmHg and diastolic below 105, without end-organ damage, do not require antihypertensive pharmacological therapy. For pregnant patients with diabetes and preexisting hypertension, who are treated with anti-hypertensive medications, blood pressure targets of 120-160 and 80- 105 mmHg are suggested.1
“While the guideline on checking for orthostatic hypotension may be based on evidence of its association with an increased risk of mortality and heart failure, clinicians will likely not do it,” stated Mark E. Molitch, MD, professor of medicine at Northwestern University's Feinberg School of Medicine, “That was simply due to time constraints.”
Dr. Molitch acknowledged there is a benefit for patients with diabetes and hypertension to lower blood pressure below 140/90, but said he looks to additional studies to buttress support for lowering it further.
"SPRINT [Systolic Blood Pressure Intervention Trial] showed lowering more…did help cardiovascular disease," he said, ''but there was no one with diabetes in that [trial].''
“The medication recommendations are important ones,” Priyathama Vellanki, MD, assistant professor of endocrinology, metabolism, and lipids at Emory University School of Medicine, told EndocrineWeb.
Dr. Vellanki said, "I think it's important for clinicians to know that for blood pressure over 160/100, we should start with two agents rather than one agent. In clinical practice, we usually add medications sequentially, that is, start with one agent first and increase if not treated appropriately."
An additional and important consideration is albuminuria. Dr. Vellanki said, "While most of us start an ACE inhibitor as a first line treatment in patients with albuminuria, we do see some patients who are put on an ACE inhibitor or an ARB even if they do not have albuminuria. I think this consensus statement clearly delineates that ACE inhibitors or ARBs do not have to be a first line [therapy] for every patient with hypertension and diabetes."
The suggestion to start lifestyle interventions earlier ''is more aggressive than previously recommended and it's aimed at preventing hypertension," she said.
George L. Bakris, MD, offered a financial disclosure as he is a consultant to Merck, Relypsa, Vascular Dynamics, GlaxoSmithKline, Bayer, Janssen, and AbbVie.