Skip to main content

Advertisement

Log in

Management of hypertension and diabetes: Treatment goals, drug choices, current practice, and strategies for improving care

  • Published:
Current Hypertension Reports Aims and scope Submit manuscript

Abstract

Diabetes and hypertension are common coexistent conditions, the combination of which results in an increased risk for cardiovascular and renal disease. Clinical trials have convincingly demonstrated the benefit of tight blood pressure control among patients with diabetes in reducing these risks. Furthermore, the choice of medication is less important than the level of control, especially in patients without renal involvement. Despite widespread dissemination of guidelines advocating tight control, many patients with diabetes continue to have uncontrolled blood pressure. The reasons for this are likely due to two main factors: blood pressure is more difficult to control in patients with diabetes, and providers are not treating these patients aggressively enough. Although the optimal approach to changing provider behavior and improving hypertension control is unknown, it likely involves a multi-faceted intervention that includes a disease management approach and targets multiple barriers to care, including those related to the providers, patients, and the health care organization.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References and Recommended Reading

  1. Gress TW, Nieto FJ, Shahar E, et al.: Hypertension and antihypertensive therapy as risk factors for type 2 diabetes mellitus. Atherosclerosis Risk in Communities Study. N Engl J Med 2000, 342:905–912.

    Article  PubMed  CAS  Google Scholar 

  2. Berlowitz DR, Ash AS, Hickey EC, et al.: Hypertension management in patients with diabetes: the need for more aggressive therapy. Diabetes Care 2003, 26:355–359. Cohort study analyzing BP treatment in diabetic hypertensive veterans compared with treatment in those with hypertension alone. Diabetic subjects had worse rates of BP control, and, despite this, providers made fewer medication increases than in those without diabetes.

    Article  PubMed  Google Scholar 

  3. Godley PJ, Maue SK, Farrelly EW, Frech F: The need for improved medical management of patients with concomitant hypertension and type 2 diabetes mellitus. Am J Manag Care 2005, 11:206–210.

    PubMed  Google Scholar 

  4. Geiss LS, Rolka DB, Engelgau MM: Elevated blood pressure among U.S. adults with diabetes, 1988–1994. Am J Prev Med 2002, 22:42–48.

    Article  PubMed  Google Scholar 

  5. Hajjar I, Kotchen TA: Trends in prevalence, awareness, treatment, and control of hypertension in the United States, 1988–2000. JAMA 2003, 290:199–206.

    Article  PubMed  Google Scholar 

  6. DeStefano F, Ford ES, Newman J, et al.: Risk factors for coronary heart disease mortality among persons with diabetes. Ann Epidemiol 1993, 3:27–34.

    Article  PubMed  CAS  Google Scholar 

  7. Arauz-Pacheco C, Parrott MA, Raskin P: Treatment of hypertension in adults with diabetes. Diabetes Care 2003, 26(Suppl 1):S80-S82.

    PubMed  Google Scholar 

  8. US Renal Data System: USRDS 2004 Annual Data Report: Atlas of End-Stage Renal Disease in the United States. Bethesda, MD: National Institute of Diabetes and Digestive and Kidney Diseases; 2005. Available at: http://www.usrds.org

  9. Curb JD, Pressel SL, Cutler JA, et al.: Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic Hypertension in the Elderly Program Cooperative Research Group. JAMA 1996, 276:1886–1892.

    Article  PubMed  CAS  Google Scholar 

  10. Tuomilehto J, Rastenyte D, Birkenhager WH, et al.: Effects of calcium-channel blockade in older patients with diabetes and systolic hypertension. Systolic Hypertension in Europe Trial Investigators. N Engl J Med 1999, 340:677–684.

    Article  PubMed  CAS  Google Scholar 

  11. Arauz-Pacheco C, Parrott MA, Raskin P: The treatment of hypertension in adult patients with diabetes. Diabetes Care 2002, 25:134–147.

    Article  PubMed  Google Scholar 

  12. Hansson L, Zanchetti A, Carruthers SG, et al.: Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial. HOT Study Group. Lancet 1998, 351:1755–1762.

    Article  PubMed  CAS  Google Scholar 

  13. Estacio RO, Jeffers BW, Hiatt WR, et al.: The effect of nisoldipine as compared with enalapril on cardiovascular outcomes in patients with non-insulin-dependent diabetes and hypertension. N Engl J Med 1998, 338:645–652.

    Article  PubMed  CAS  Google Scholar 

  14. Estacio RO, Jeffers BW, Gifford N, Schrier RW: Effect of blood pressure control on diabetic microvascular complications in patients with hypertension and type 2 diabetes. Diabetes Care 2000, 23(Suppl 2):B54-B64.

    PubMed  Google Scholar 

  15. Schrier RW, Estacio RO, Esler A, Mehler P: Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002, 61:1086–1097.

    Article  PubMed  Google Scholar 

  16. UK Prospective Diabetes Study Group: Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. BMJ 1998, 317:703–713.

    Google Scholar 

  17. UK Prospective Diabetes Study (UKPDS) Group: Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998, 352:837–853.

    Article  Google Scholar 

  18. Adler AI, Stratton IM, Neil HA, et al.: Association of systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36): prospective observational study. BMJ 2000, 321:412–419.

    Article  PubMed  CAS  Google Scholar 

  19. Bakris GL, Weir MR, Shanifar S, et al.: Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Intern Med 2003, 163:1555–1565.

    Article  PubMed  Google Scholar 

  20. Joint National Committee: The sixth report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Arch Intern Med 1997, 157:2413–2446.

    Article  Google Scholar 

  21. Chobanian AV, Bakris GL, Black HR, et al.: The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA 2003, 289:2560–2572.

    Article  PubMed  CAS  Google Scholar 

  22. Guidelines Committee: 2003 European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J Hypertens 2003, 21:1011–1053.

    Article  Google Scholar 

  23. 2004 Canadian Hypertension Education Program Recommendations: Executive Summary. http://www.hypertension.ca/ Documentation/CHEP2004_exec_summary.pdf. Accessed June 24, 2005.

  24. Williams B, Poulter NR, Brown MJ, et al.: British Hypertension Society guidelines for hypertension management 2004 (BHSIV): summary. BMJ 2004, 328:634–640.

    Article  PubMed  Google Scholar 

  25. Office of Performance and Quality: VHA/DOD Clinical Practice Guideline for Diagnosis and Managment of Hypertension in the Primary Care Setting. http://www.oqp.med.va.gov/ cpg/HTN/HTN_Base.htm. Accessed June 1, 2005.

  26. Lewis EJ, Hunsicker LG, Bain RP, Rohde RD: The effect of angiotensin-converting-enzyme inhibition on diabetic nephropathy. The Collaborative Study Group. N Engl J Med 1993, 329:1456–1462.

    Article  PubMed  CAS  Google Scholar 

  27. Andersen S, Tarnow L, Rossing P, et al.: Renoprotective effects of angiotensin II receptor blockade in type 1 diabetic patients with diabetic nephropathy. Kidney Int 2000, 57:601–606.

    Article  PubMed  CAS  Google Scholar 

  28. Brenner BM, Cooper ME, de Zeeuw D, et al.: Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med 2001, 345:861–869.

    Article  PubMed  CAS  Google Scholar 

  29. Parving HH, Lehnert H, Brochner-Mortensen J, et al.: The effect of irbesartan on the development of diabetic nephropathy in patients with type 2 diabetes. N Engl J Med 2001, 345:870–878.

    Article  PubMed  CAS  Google Scholar 

  30. Pahor M, Psaty BM, Alderman MH, et al.: Therapeutic benefits of ACE inhibitors and other antihypertensive drugs in patients with type 2 diabetes. Diabetes Care 2000, 23:888–892.

    Article  PubMed  CAS  Google Scholar 

  31. UK Prospective Diabetes Study Group: Efficacy of atenolol and captopril in reducing risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 39. BMJ 1998, 317:713–720.

    Google Scholar 

  32. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). JAMA 2002, 288:2981–2997. This randomized trial demonstrates the equivalency of a thiazide diuretic, ACE inhibitor, and a dihydropyridine CCB in preventing major cardiovascular outcomes in hypertensive high-risk patients, including those with diabetes. (A slight increased risk of heart failure was found in those on the ACEI or CCB compared to the thiazide, which has been at least partly attributed to the slightly higher final BPs seen in the these groups or perhaps masking of heart failure symptoms with the diuretic.)

    Article  Google Scholar 

  33. Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group. JAMA 2000, 283:1967–1975.

  34. Barzilay JI, Davis BR, Bettencourt J, et al.: Cardiovascular outcomes using doxazosin vs. chlorthalidone for the treatment of hypertension in older adults with and without glucose disorders: a report from the ALLHAT study. J Clin Hypertens (Greenwich) 2004, 6:116–125.

    CAS  Google Scholar 

  35. Whelton PK, Barzilay J, Cushman WC, et al.: Clinical outcomes in antihypertensive treatment of type 2 diabetes, impaired fasting glucose concentration, and normoglycemia: Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2005, 165:1401–1409.

    Article  PubMed  CAS  Google Scholar 

  36. Rahman M, Pressel S, Davis BR, et al.: Renal outcomes in highrisk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med 2005, 165:936–946.

    Article  PubMed  CAS  Google Scholar 

  37. Turnbull F, Neal B, Algert C, et al.: Effects of different blood pressure-lowering regimens on major cardiovascular events in individuals with and without diabetes mellitus: results of prospectively designed overviews of randomized trials. Arch Intern Med 2005, 165:1410–1419.

    Article  PubMed  Google Scholar 

  38. Lindholm LH, Ibsen H, Dahlof B, et al.: Cardiovascular morbidity and mortality in patients with diabetes in the Losartan Intervention for Endpoint reduction in hypertension study (LIFE): a randomised trial against atenolol. Lancet 2002, 359:1004–1010.

    Article  PubMed  CAS  Google Scholar 

  39. Tatti P, Pahor M, Byington RP, et al.: Outcome results of the Fosinopril Versus Amlodipine Cardiovascular Events Randomized Trial (FACET) in patients with hypertension and NIDDM. Diabetes Care 1998, 21:597–603.

    Article  PubMed  CAS  Google Scholar 

  40. Neal B, MacMahon S, Chapman N: Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet 2000, 356:1955–1964.

    Article  PubMed  CAS  Google Scholar 

  41. Bakris GL, Williams M, Dworkin L, et al.: Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis 2000, 36:646–661.

    PubMed  CAS  Google Scholar 

  42. Burt VL, Whelton P, Roccella EJ, et al.: Prevalence of hypertension in the US adult population. Results from the Third National Health and Nutrition Examination Survey, 1988–1991. Hypertension 1995, 25:305–313.

    PubMed  CAS  Google Scholar 

  43. Borzecki AM, Wong AT, Hickey EC, et al.: Hypertension control: How well are we doing? Arch Intern Med 2003, 163:2705–2711.

    Article  PubMed  Google Scholar 

  44. Cushman WC, Ford CE, Cutler JA, et al.: Success and predictors of blood pressure control in diverse North American settings: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). J Clin Hypertens 2002, 4:393–405. Secondary analysis of ALLHAT data examining rates of BP control and medication use among subgroups including those with diabetes, as well as predictors of BP control.

    Google Scholar 

  45. Huggett RJ, Scott EM, Gilbey SG, et al.: Impact of type 2 diabetes mellitus on sympathetic neural mechanisms in hypertension. Circulation 2003, 108:3097–3101.

    Article  PubMed  CAS  Google Scholar 

  46. Chiasson JL, Josse RG, Gomis R, et al.: Acarbose for prevention of type 2 diabetes mellitus: the STOP-NIDDM randomised trial. Lancet 2002, 359:2072–2077.

    Article  PubMed  CAS  Google Scholar 

  47. Sarafidis PA, Lasaridis AN, Nilsson PM, et al.: Ambulatory blood pressure reduction after rosiglitazone treatment in patients with type 2 diabetes and hypertension correlates with insulin sensitivity increase. J Hypertens 2004, 22:1769–1777.

    Article  PubMed  CAS  Google Scholar 

  48. Borzecki AM, Oliveria SA, Berlowitz DR: Barriers to hypertension control. Am Heart J 2005, 149:785–794.

    Article  PubMed  Google Scholar 

  49. Berlowitz DR, Ash AS, Hickey EC, et al.: Inadequate management of blood pressure in a hypertensive population. N Engl J Med 1998, 339(27):1957–1963.

    Article  PubMed  CAS  Google Scholar 

  50. Phillips LS, Branch WT, Cook CB, et al.: Clinical inertia. Ann Intern Med 2001, 135:825–834.

    PubMed  CAS  Google Scholar 

  51. Oliveria SA, Lapuerta P, McCarthy BD, et al.: Physician-related barriers to the effective management of uncontrolled hypertension. Arch Intern Med 2002, 162:413–420.

    Article  PubMed  Google Scholar 

  52. Pellegrini F, Belfiglio M, De Berardis G, et al.: Role of organizational factors in poor blood pressure control in patients with type 2 diabetes: the QuED Study Group—quality of care and outcomes in type 2 diabetes. Arch Intern Med 2003, 163:473–480.

    Article  PubMed  Google Scholar 

  53. Grimshaw JM, Shirran L, Thomas R, et al.: Changing provider behavior: an overview of systematic reviews of interventions. Med Care 2001, 39(8 Suppl 2):II2-II45.

    Article  PubMed  CAS  Google Scholar 

  54. Oxman AD, Thomson MA, Davis DA, Haynes RB: No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995, 153:1423–1431.

    PubMed  CAS  Google Scholar 

  55. New JP, Mason JM, Freemantle N, et al.: Specialist nurse-led intervention to treat and control hypertension and hyperlipidemia in diabetes (SPLINT): a randomized controlled trial. Diabetes Care 2003, 26:2250–2255.

    Article  PubMed  Google Scholar 

  56. Denver EA, Barnard M, Woolfson RG, Earle KA: Management of uncontrolled hypertension in a nurse-led clinic compared with conventional care for patients with type 2 diabetes. Diabetes Care 2003, 26:2256–2260.

    Article  PubMed  Google Scholar 

  57. Taylor CB, Miller NH, Reilly KR, et al.: Evaluation of a nursecare management system to improve outcomes in patients with complicated diabetes. Diabetes Care 2003, 26:1058–1063.

    Article  PubMed  Google Scholar 

  58. Krein SL, Klamerus ML, Vijan S, et al.: Case management for patients with poorly controlled diabetes: a randomized trial. Am J Med 2004, 116:732–739.

    Article  PubMed  Google Scholar 

  59. Grol R: Personal paper. Beliefs and evidence in changing clinical practice. BMJ 1997, 315:418–421.

    PubMed  CAS  Google Scholar 

  60. Shojania KG, McDonald KM, Wachter RM, Owens DK: Closing the quality gap: a critical analysis of quality improvement strategies. Volume 1: Series overview and methodology. AHRQ Publication No. 04-0051-1. In Rockville, MD: Agency for Healthcare Research and Quality; 2004.

    Google Scholar 

  61. Shojania KG, Ranjii SR, Shaw LK, et al.: Closing the quality gap: a critical analysis of quality improvement strategies. Volume 2: Diabetes mellitus care. AHRQ Publication No. 04-0051-2. In Rockville, MD: Agency for Healthcare Research and Quality; 2004. Systematic review designed to identify successful interventions in improving patient outcomes via changes in provider behavior or organizational change with respect to diabetes care. Provider education and organizational changes —specifically disease management —showed the most benefit in improving glycemic control. (Disease management had the largest effect on BP control in a similar hypertension review.)

    Google Scholar 

  62. Walsh J, McDonald KM, Shojania KG, et al.: Closing the quality gap: a critical analysis of quality improvement strategies. Volume 3: Hypertension care. AHRQ Publication No. 04-0051-3. In Rockville, MD: Agency for Healthcare Research and Quality; 2005.

    Google Scholar 

  63. Chobanian AV: Control of hypertension—an important national priority. N Engl J Med 2001, 345:534–535.

    Article  PubMed  CAS  Google Scholar 

  64. National Diabetes Education Program: Be Smart About Your Heart. Control the ABCs of Diabetes. http://ndep.nih.gov/campaigns/ BeSmart/BeSmart_index.htm. Accessed June 29, 2005.

  65. Grimshaw JM, Russell IT: Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993, 342:1317–1322.

    Article  PubMed  CAS  Google Scholar 

  66. Haynes RB, McDonald H, Garg AX, Montague P: Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev 2002, 2:CD000011.

    PubMed  Google Scholar 

  67. Hansson L, Lindholm LH, Niskanen L, et al.: Effect of angiotensin-converting-enzyme inhibition compared with conventional therapy on cardiovascular morbidity and mortality in hypertension: the Captopril Prevention Project (CAPPP) randomised trial. Lancet 1999, 353:611–616.

    Article  PubMed  CAS  Google Scholar 

  68. Niskanen L, Hedner T, Hansson L, et al.: Reduced cardiovascular morbidity and mortality in hypertensive diabetic patients on first-line therapy with an ACE inhibitor compared with a diuretic/beta-blocker-based treatment regimen: a subanalysis of the Captopril Prevention Project. Diabetes Care 2001, 24:2091–2096.

    Article  PubMed  CAS  Google Scholar 

  69. Hansson L, Hedner T, Lund-Johansen P, et al.: Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet 2000, 356:359–365.

    Article  PubMed  CAS  Google Scholar 

  70. Smith NL, Savage PJ, Heckbert SR, et al.: Glucose, blood pressure, and lipid control in older people with and without diabetes mellitus: the Cardiovascular Health Study. J Am Geriatr Soc 2002, 50:416–423.

    Article  PubMed  Google Scholar 

  71. Smith NL, Chen L, Au DH, et al.: Cardiovascular risk factor control among veterans with diabetes: the ambulatory care quality improvement project. Diabetes Care 2004, 27(Suppl 2):B33-B38.

    Article  PubMed  Google Scholar 

  72. McFarlane SI, Jacober SJ, Winer N, et al.: Control of cardiovascular risk factors in patients with diabetes and hypertension at urban academic medical centers. Diabetes Care 2002, 25:718–723.

    Article  PubMed  Google Scholar 

  73. Singer GM, Izhar M, Black HR: Guidelines for hypertension: Are quality-assurance measures on target? Hypertension 2004, 43:198–202.

    Article  PubMed  CAS  Google Scholar 

  74. Duggirala MK, Cuddihy RM, Cuddihy MT, et al.: Predictors of blood pressure control in patients with diabetes and hypertension seen in primary care clinics. Am J Hypertens 2005, 18:833–838.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

About this article

Cite this article

Borzecki, A.M., Berlowitz, D.R. Management of hypertension and diabetes: Treatment goals, drug choices, current practice, and strategies for improving care. Current Science Inc 7, 439–449 (2005). https://doi.org/10.1007/s11906-005-0039-7

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11906-005-0039-7

Keywords

Navigation