Hypertension in Diabetics

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Hypertension in Diabetics

Introduction

The number of people with diabetes (high blood sugar) in the U.S.

continues to increase due to our aging population, sedentary

lifestyle, and the number of overweight (obese) people. Hypertension

(high blood pressure) is twice as common in people with diabetes than

in people without diabetes.

There are two types of diabetes: the classic insulin-dependent form,

or type 1 (often diagnosed at a young age and makes up about ten

percent of all diabetics), and the insulin-independent form, or type

2 (usually presents around middle age and accounts for 90 percent of

all diabetics.)

In the two types of diabetes, obesity is present in most of the

people with type 2. Hypertension is also more common in people with

type 2 diabetes.

On the other hand, kidney malfunction (nephropathy) is very common in

type 1 diabetics—present in about 40 percent. In general, diabetics

have increased risks of stroke, heart attack, heart failure, and

peripheral vascular disease than non-diabetics. These risks are

increased further in the presence of hypertension.

How Does Diabetes Cause Hypertension?

Although we don't know all the reasons why hypertension is very

common in diabetics, the little that we do know allows the belief

that it is the increase in blood insulin in both types of diabetes

that promotes hypertension by affecting key checkpoints in the body.

For example, increased blood insulin makes the blood vessels widen

(vasodilate) and this widening of the blood vessels affects the

sympathetic nervous system that increases blood pressure (BP),

directly or indirectly, by making the kidney retain salt. Another way

the increase in blood insulin can lead to increased blood pressure is

by promoting atherosclerosis, which hardens the blood vessels.

It is also believed that those diabetics (especially type 2) who live

with untreated high blood sugar for a long time are more likely to

have hypertension due to early atherosclerosis.

What Blood Pressure is Considered Abnormal if I am Diabetic?

The patients with type 2 diabetes and/or family history of both

diabetes and hypertension should be encouraged to have their blood

pressures followed very closely. Usually, if the blood pressure

remains equal or greater than 140/90 over two or more weeks of

several measurements, the diagnosis of hypertension is made. However,

the diagnosis of hypertension has to be entertained and probably be

made if you are diabetic and have blood pressure in the borderline

range of 130-139/85-89 mm Hg.

The Importance of Lifestyle Modification (Weight Loss, Exercise, and

Diet)

Lifestyle modification in the form of weight loss through exercise

and diet is particularly important in diabetics. Obesity increases

your chances of having diabetes (especially type 2) and/or

hypertension. It is generally agreed that the best way to prevent

hypertension or to reduce BP is to maintain ideal body weight or lose

weight if you are obese. Many of the patients often ask what ideal

body weight means and how they can find theirs. Ideal body weight is

basically a weight that is calculated using your height and your sex,

matched against a standard (what an average person of your height and

sex should be). It is different for men and women.

Ideal body weight

For example, to estimate the ideal body weight of a woman with height

of five feet, three inches, you will allow 100 pounds for the five

feet and then add five pounds for each additional inch. Therefore,

the above woman's ideal body weight will be 115 pounds (five feet =

100 pounds, three inches = 15 pounds (5 x 3). For men you allow 106

pounds for five feet and six pounds for each additional inch, making

the ideal body weight for the assumed man to be 124 pounds. If the

woman in the above example is a patient with diabetes and weighed 138

pounds (20 percent over ideal weight for a five-foot, three-inch tall

woman), a weight reduction program for her even if she has no

hypertension at this time should be recommended.

If she were ten percent or less over her ideal weight, she should not

be recommended anything, but fewer calories each day. One way to

estimate the number of calories needed to maintain an ideal body

weight is to determine the activity level of the person. For example,

a very active person has activity level of 17, relatively active =

15, inactive = 13. So if the above patient is relatively active

(activity level = 15), the total calorie need per day to maintain her

ideal body weight of 115 pounds will be 1,725 calories (115 x 15).

A healthy diet for her should consist of food low in saturated fat

and total fat, low in salt and cholesterol, but high in fiber. The

goal is to maintain a diet with no more than 30 percent of calories

from fat (approximately 20 percent unsaturated fat and 10 percent

saturated fat). The patients should eat multiple servings of fruits,

vegetables, and variety of grains (cereal, rice, etc.), especially

whole grains, low-fat dairy products, and low-calorie soft drinks.

For exercise, at least 30 minutes of moderate exercise (biking,

swimming, walking, and jogging) a day for adults and about 60 minutes

for younger patients should be recommended.

Beginning Drug Therapy and Target Blood Pressure

Usually antihypertensive drug therapy (blood pressure medication)

should be initiated in addition to lifestyle modification as soon as

any of the diabetic patients is found to have high normal BP (130-

39/85-89). This treatment strategy is different and more aggressive

compared to treatment of hypertension in people without diabetes in

whom lifestyle modification alone would have been the initial

approach. Reduction of BP in diabetics saves lives from complications

of heart disease.

The ideal BP target in diabetics is 120/80 or below, although this

target is lower than target BP in people without diabetes, clinical

trials have shown that this target is most beneficial in terms of

reducing complications in this population of patients.

What Drugs are Best for Me?

Angiotensin-Converting Enzyme Inhibitors (ACEIs) (Lisinopril,

Enalapril, Ramipril, or Captopril) should be the preferred first-line

drugs for the treatment of hypertension in diabetics, especially in

type 1 diabetics with nephropathy and/or heart failure. The benefits

of the ACEIs over other medications include:

Prolongation of life in diabetics with hypertension and heart failure

improvement in exercise tolerance

Reduction in the level of angiotensin II in the blood (angiotensin II

has negative effect to the functions of the heart).

These drugs also have no effect on glucose or lipids, decrease

proteinuria (protein in the urine) and rate of kidney damage.

They rarely cause orthostatic hypotension, rarely cause impotence and

minimize adverse metabolic effects of diuretics when used together.

Angiotensin-Receptor Blocker (ARBs) such as Losartan, Irbesartan, or

Candesartan are similar to the ACEIs in their action, but have fewer

side effects of coughing and rash that are seen in the use of ACEIs.

Some clinical studies have found them to be effective in controlling

blood pressure, however, they have not been around as long as the

ACEIs and clinical trials have not confirmed and compared their

effects in a large number of patients (such studies are still

ongoing). They are, therefore, not used as first-line agents all the

time. They should be tried for diabetic patients with hypertension

and/or heart failure if they cannot tolerate the ACEIs due to

persistent cough or rash.

Other medical problems that the diabetic patients have (e.g.,

irregular heartbeats, benign prostatic hyperplasia (BPH),

osteoporosis, angina, isolated systolic hypertension (ISH), or heart

failure help guide the choice of medications should be used in

conjunction with first-line agents. For example, in those diabetics

with history of angina, prior heart attack, or irregular heartbeats,

a beta-blocker like Atenolol, Bisoprolol, or Metoprolol should be

used. These drugs reduce blood pressure in addition to reducing the

amount of work the heart has to do by reducing heart rate

and " pumping of the heart " (cardiac output) They have been shown to

prevent second heart attacks and dangerous abnormal heartbeats

(arrhythmias).

For diabetic male patients with BPH and hypertension, an alpha-

adrenergic blocker (drugs like Doxazosin, Prazosin, or Terazosin)

should be added to an ACEI. These drugs reduce the symptoms of BPH by

their action on smooth muscles as well as help control BP. In

general, these medications at a low dose of the long-acting, once-

daily formulations and increase gradually until maximum dose is

achieved depending on patient response may be recommended.

The physician should consider a second agent from a different class

if, while the patient is tolerating the first agent, BP control is

not achieved. Sometimes the first medication should be withdrawn

completely and substitute with a medication from a different class if

there are too many side effects or if the drug is not effective. It

is not uncommon for me to use three medications from different groups

in order to achieve desired blood pressure in some of the diabetic

patients.

Conclusion

It is important to follow blood sugar and blood pressure very closely

in diabetics for early diagnosis and prompt initiation of therapy.

This strategy will help reduce complications associated with these

diseases. However, the most critical factor in controlling both

diabetes and hypertension is weight reduction through exercise and

diet. Since drug therapy is recommended for all diabetics at all

stages of hypertension (mild, moderate and severe), antihypertensives

should be chosen carefully and special attention should be paid to

their side effects.

Monitoring of lipid levels (cholesterol, etc.) and blood sugar levels

are important because some blood pressure medications may affect

their levels. With early diagnosis, weight reduction through diet and

exercise, choice of appropriate medication, and close monitoring,

hypertension in diabetics will have fewer complications.