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Treatment of Hypertension in Patients with Type 2 Diabetes
An ACP guideline recommends tight blood pressure control for diabetics.
How aggressive should antihypertensive therapy be, and which drugs should be used to treat hypertension, in adults with type 2 diabetes? A recent randomized trial, an evidence review, and a practice guideline provide some guidance.
In the randomized trial, investigators compared irbesartan (an angiotensin-receptor blocker), amlodipine (a calcium-channel blocker), and placebo. A manufacturer of irbesartan sponsored the trial. Patients had blood pressure higher than 135/85 mm Hg and either were being treated for hypertension or had proteinuria (
900 mg daily) and high serum creatinine levels (1 mg/dL [1.2 mg/dL for men] to 3 mg/dL). By the end of the trial, patients in each group -- including the placebo group -- were receiving an average of 3 antihypertensive drugs; thus, the trial was not truly a comparison between active therapy and no therapy. Previous results from this study demonstrated that irbesartan conferred renoprotection (Journal Watch Sep 28 2001). In this report of secondary cardiovascular outcomes, no significant differences in a composite endpoint (cardiovascular death, myocardial infarction, heart failure, stroke, and unplanned revascularization) were seen among the 3 groups after a median follow-up of 2.6 years. Irbesartan was associated with a significantly lower hazard for heart failure than was placebo or amlodipine but also with a trend toward a higher hazard for MI. Compared with placebo, amlodipine protected against MI.
Three randomized trials of antihypertensive therapy versus placebo for patients with diabetes were identified in an evidence review. Reductions in cardiovascular events occurred with active therapy in all trials. In 3 other trials, tighter BP control (mean, 132/78 mm Hg) led to improved clinical outcomes (e.g., lower mortality, fewer cardiovascular events and microvascular complications). Studies yielded conflicting results regarding preferred drugs.
Guidelines from an American College of Physicians committee recommend that hypertension in type 2 diabetes be managed by tight BP control, with a goal of 135/80 mm Hg. Thiazide diuretics and angiotensin-converting-enzyme inhibitors are recommended as first-line therapy. Two authors of the evidence review added angiotensin-receptor blockers to that list, based on renal benefits.
Comment: It is difficult to perform a study of single antihypertensive drugs that is long enough to determine the most important outcome, which is all-cause mortality. Given conflicting results and limited data, any guidelines should be modified based on individual patient characteristics (for example, ß-blockers for coronary disease). And, the choice of drug probably is less important than is blood pressure lowering in patients with diabetes. At the time of publication the full text of the evidence review and guidelines was available at http://www.annals.org/issues/v138n7/full/200304010-00017.html and http://www.annals.org/issues/v138n7/full/200304010-00018.html free of charge.
— Richard Saitz, MD, MPH
Published in Journal Watch General Medicine April 29, 2003
Citation(s):
Berl T et al. Cardiovascular outcomes in the Irbesartan Diabetic Nephropathy Trial of patients with type 2 diabetes and overt nephropathy. Ann Intern Med 2003 Apr 1; 138:542-9.
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Snow V et al. The evidence base for tight blood pressure control in the management of type 2 diabetes mellitus. Ann Intern Med 2003 Apr 1; 138:587-92.
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Vijan S and Hayward RA. Treatment of hypertension in type 2 diabetes mellitus: Blood pressure goals, choice of agents, and setting priorities in diabetes care. Ann Intern Med 2003 Apr 1; 138:593-602.
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- Medline abstract (Free)