Treatment Of Hypertension In Diabetes
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Transcript of Treatment Of Hypertension In Diabetes
BY
Dr. Khaled HelmyAl Mahmora Chest Hospital
BY
Dr. Khaled HelmyAl Mahmora Chest Hospital
Treatment Of HypertensionIn Diabetes
Treatment Of HypertensionIn Diabetes
Hypertension
&
Diabetes
Hypertension
&
Diabetes
Hypertension affecting 20–60% of patients with diabetes.
In type 2 diabetes, hypertension is often present as part of the metabolic syndrome while in type 1 diabetes, hypertension may reflect the onset of diabetic nephropathy.
Hypertension substantially increases the risk of both macrovascular and microvascular complications.
Hypertensive diabetic patients are also at increased
risk for diabetes-specific complications including
retinopathy and nephropathy.
In recent years, adequate data from well-designed
randomized clinical trials have demonstrated the effectiveness of aggressive treatment of hypertension in reducing both types of diabetes complications.
Hypertension Diabetes Hypertension Diabetes
Diabetes increases the risk of coronary events twofold in men and fourfold in women after menopause.
People with both diabetes and hypertension have approximately twice the risk of cardiovascular disease as non-diabetic people with hypertension
In the U.K. Prospective Diabetes Study (UKPDS) epidemiological study, each 10-mmHg decrease in mean systolic blood pressure was associated with reductions in risk of 12% for any complication related to diabetes, 15% for deaths related to diabetes, 11% for myocardial infarction, and 13% for microvascular complications.
Hypertension Diabetes Hypertension Diabetes
Normotensive HypertensionNormotensive Hypertension
In recent years, adequate data from well-designed
randomized clinical trials have demonstrated that structural changes in vessels start 5 years before BP elevated .
patients who still have normal BP but have the high risk to develop high Bp(Patient at risk) are classified as normotensive hypertension and of course one of them is diabetic patients and they should be managed as soon as possible .
Strategy for management of Hypertensive Diabetic pts
Strategy for management of Hypertensive Diabetic pts
Proper blood sugar control .
Achieve target level of BP control for
diabetic patients
Early Detection of both diabetes and
hypertension complications & manage them
as well as delay their progression
Improve patients quality of life .
Target levels of blood pressure in patients with Diabetes
Target levels of blood pressure in patients with Diabetes
The UKPDS and the Hypertension Optimal Treatment
(HOT) trial both demonstrated improved outcomes ,
especially in preventing stroke, in patients assigned to
lower blood pressure targets.
A target blood pressure goal of <130/80 mmHg is
reasonable if it can be safely achieved <125/75 mmHg
(in proteinuria >0.5-1g/d)
It is very clear that many people will require more than
one drug to achieve the recommended target.
Non-drug management of Hypertension
Non-drug management of Hypertension
Moderate sodium restriction ,reduce salt intake from 200mmol
(4600 mg) to 100mmol (2300 mg) daily 5 mm fall in DBP.
Weight reduction (Loss of 1 kg weight decrease mean
arterial pressure of about 1 mm Hg.
Moderately intense physical activity: 30-45 mins of brisk
walking most days of the week has been shown to reduce BP.
Stop smoking decease micro, macrovasular Compilications
Role of very low calorie diets ?
Pharmacologic agents that induce weight loss?
Drug therapy of Hypertension in Diabetes
Drug therapy of Hypertension in Diabetes
There is strong evidence that pharmacological
therapy of hypertension in patients with diabetes
is effective in producing substantial decreases in
cardiovascular and micro vascular diseases.
It must be noted that many patients required more
than one drug to achieve the specified target
levels of blood pressure control.
The UKPDS-Hypertension in Diabetes Study showed
no significant difference in outcomes for treatment
based on an ACE inhibitor compared with a ß-blocker.
Drug therapy of Hypertension in Diabetes,cont
Drug therapy of Hypertension in Diabetes,cont
ACE inhibitors and ß-blockers appear to be superior to DCCBs therefore, DCCBs appear to be appropriate agents in addition to but not instead of ACE inhibitors , and ß-blockers .
The UKPDS-Hypertension in Diabetes Study showed
no significant difference in outcomes for treatment
based on an ACE inhibitor compared with a ß-blocker.
There are no long-term studies of the effect of ß -blockers, loop diuretics, or centrally acting adrenergic blockers on long-term complications of diabetes
A variety of trials have demonstrated that ACEIs / ARBs therapy should be considered the standard therapy to retard worsening albuminuria and subsequent renal disease.
In Addition to their proper BP control, ACE inhibitors can
retard the progression of microalbuminuria and can lower
the percentage of patient who progress to end-stage
renal disease and death.
All patients with asymptomatic or symptomatic heart failure due to left ventricular systolic dysfunction should receive an ACE inhibitor. Approximately 50% of patients post-MI have significant left ventricular dysfunction and could benefits from ACE inhibitor therapy.
Role of ACEIs & ARBs in DiabetesRole of ACEIs & ARBs in Diabetes
A meta-analysis of 20 published and two unpublished
trials was carried out to determine whether ACE inhibitors
could slow the progression of renal disease of varying
degree showed that treatment of chronic renal insufficiency
with ACE inhibitors delayed the progression of disease
compared with placebo.
ACE inhibitors have a favorable effect on cardiovascular
outcomes , this cardiovascular effect may be mediated by
mechanisms other than blood pressure reduction.
Role of ACEIs & ARBs in Diabetes,contRole of ACEIs & ARBs in Diabetes,cont
Role of ACEIs & ARBs in Diabetes ,contRole of ACEIs & ARBs in Diabetes ,cont
There are numerous studies documenting the effectiveness Of ACE inhibitors and ARBs in retarding the development and progression of diabetic complications : EUCLID Study (Lisinopril vs placebo) Type1 Diabetic retinopathy CALM study (Lisinopril vs Candestran & combination) BP & Microalbuminurea RENAAL study(Losartan vs placebo) Type 1 Diabetic nephropathy HOPE study (Ramiplil vs placebo) Reduction of MI,stroke ,CV death All- cause death in high risk pts esp DM. IDNT study (Irbesartan vs amlodipine vs placebo) MARVAL study (Valsartan) Type 2 Diabetic nephropathy Irbesartan & Valsartan delay nephropathy amlodipine no better than placebo
ACEIs Vs ARBsACEIs Vs ARBs
Angiotensinogen Other Substrates?
Angiotensin I
Angiotensin II
Bradykinin & other substrates
Psychological actionsActions?
AT2 AT1
Renin
ACE
Renin Blockade
ACE inhibitors
Angiotensin II receptor antagonists
blocking the Renin-Angiotensin
system
?
ACEIs Vs ARBsACEIs Vs ARBs
ACEIs Vs ARBsACEIs Vs ARBs
Evidence for beneficial outcomes (especially renal) with ARBs is growing but varying opinion on their optimal role.
Unfortunately, several ARB outcome trials have avoided a head-to-head comparison with ACEIs.
Losartan was not superior to captopril in patients with heart failure( ELITE II) , captopril reduced CV-death in post-MI patients more than losartan( OPTIMAAL) However, both of these studies found that less patients discontinued losartan due to adverse effects
ARBs are an alternative in patients who develop ACEI induced cough but are more expensive than most ACEIs
ACEI-ARB combinations show some promise for renal outcomes( CALM, COOPERATE), however they are expensive.
Approach to Combination Therapy
The ABCD Approach
Approach to Combination Therapy
The ABCD Approach
A = ACEI or ARB B = β-blocker
C = CCB D = diuretic low-dose
If initial drug is A or B adding drug C or D
provides a synergistic effect.
If initial drug is C or D adding drug A or B
provides a synergistic effect; (C+diuretic, also option).
•Verapamil or diltiazem with a β-blocker negative effects on heart (e.g. ↓ heart rate and ↓ cardiac output)•CCBS and α-blockers potential for excessive hypotension; increased risk of falls, etc.
Thiazide like diuretic (low dose→HCT 12.5-25mg od)
B blocker (cardioselective-e.g. atenolol, metoprolol)
Long acting calcium channel blockers (amlodipine)
1st potion ACEIs
Monotherapy
Drug therapy in
Hypertension with Diabetes
Drug therapy in
Hypertension with Diabetes
2nd option ARBsOR
+ Combination
Summary
Summary
Non-pharmacological measures (particularlyweight loss
and reduction in salt intake) should be encouraged in all
patients with diabetes, independently of the existing
blood pressure.
The goal blood pressure to aim at during behavioural
or pharmacological therapy is below 130/80 mmHg.
To reach this goal, most often combination therapy
will be required.
It is recommended that all effective and well tolerated
antihypertensive agents are used, generally in combination.
In diabetic patients with high blood pressure, who
may sometimes achieve blood pressure goal
by monotherapy, the first drug to be tested should
be a blocker of the renin–angiotensinsystem
(ACE & ARBS)
The finding of microalbuminuria in type
1 or 2 diabetics is an indication for antihypertensive
treatment, especially by a blocker of the
renin–angiotensin system, irrespective of the blood
pressure values(normotesive Hypertension).
Summary,cont Summary,cont
DCCBs (compared with ACE inhibitors, ARBs,
ß-blockers, or diuretics) should be used as
second-line drugs for patients who cannot tolerate
the other preferred classes or who require additional
agents to achieve the target blood pressure.
Other classes, including Alph -blockers, may be
used under specific indications such as symptoms
of BPH.
Achievement of the target blood pressure goal with
a regimen that does not produce burdensome
side effects and is at reasonable cost to the patient
is probably more important than the specific drug strategy.
Summary,cont Summary,cont
Thank youThank you