htn & diabetes1

Management of Hypertension Management of Hypertension in Diabetesin Diabetes

Dr. Awadhesh K Sharma,MD,

Senior Resident,Department of Medicine,M.L.B. Medical College,Jhansi, UP

Diabetes: The ProblemDiabetes: The Problem

INDIA, the diabetes capital of world in next thirty years can also be the hypertension capital of world. (JAPI 2007)(:55:323-24).

Diabetes: HistoryDiabetes: History 1500 B.C.-Earliest known 1500 B.C.-Earliest known

record of diabetes record of diabetes mentioned on 3rd Dynasty mentioned on 3rd Dynasty Egyptian papyrus by Egyptian papyrus by physician Hesy-Ra; physician Hesy-Ra; mentions polyuria as a mentions polyuria as a symptom.symptom.

400 B.C.-Indian surgeon 400 B.C.-Indian surgeon Susruta describes ‘honeyed Susruta describes ‘honeyed urines’ produced by ‘big urines’ produced by ‘big eaters of rice and sugar’.eaters of rice and sugar’.

Diabetes: HistoryDiabetes: History 250 A.D.-Apollinius of Memphis 250 A.D.-Apollinius of Memphis

coins the name ‘diabetes’coins the name ‘diabetes’

1674-Thomas Willis publishes ‘The 1674-Thomas Willis publishes ‘The Diabetes or Pissing Evil’. Writes Diabetes or Pissing Evil’. Writes ‘those laboring with this Disease, ‘those laboring with this Disease, piss a great deal more than they piss a great deal more than they drink’ asserting that all diabetic drink’ asserting that all diabetic urine ‘was wonderfully sweet as if it urine ‘was wonderfully sweet as if it were imbued with Honey or Sugar’were imbued with Honey or Sugar’

Diabetes: HistoryDiabetes: History 1798- John Rollo documents excess sugar in blood 1798- John Rollo documents excess sugar in blood

and urineand urine 1813- Claude Bernard links diabetes with glycogen 1813- Claude Bernard links diabetes with glycogen

metabolismmetabolism 1869- Paul Langerhans (German medical student) 1869- Paul Langerhans (German medical student)

finds islets in the pancreas, but is unable to explain finds islets in the pancreas, but is unable to explain functionfunction

1889- von Mehring and Minkowski prove that 1889- von Mehring and Minkowski prove that diabetes develops when they remove the pancreas diabetes develops when they remove the pancreas of dogsof dogs

Diabetes: HistoryDiabetes: History 1910- English physiologist, Sir 1910- English physiologist, Sir

Edward Albert Sharpey-Schafer, Edward Albert Sharpey-Schafer, suggested that a single chemical suggested that a single chemical component was missing from the component was missing from the pancreas of diabetics and called it pancreas of diabetics and called it “insulin”. “insulin”.

1922- Banting and Best (a medical 1922- Banting and Best (a medical student) isolate insulin (‘ilsetin’ or student) isolate insulin (‘ilsetin’ or ‘iletin’) and inject the ‘thick brown ‘iletin’) and inject the ‘thick brown muck’ into a 14 year old boy (7.5 muck’ into a 14 year old boy (7.5 ml into each buttock) producing ml into each buttock) producing some fall in glucose complicated some fall in glucose complicated by abscesses by abscesses

Diabetes: HistoryDiabetes: History 1922- Collip refines the extract and re-

injects it in the boy with glucose falling from 520 to 120 mg/dl in 24 hours

Diabetes: HistoryDiabetes: HistoryBantingMacleod

CollipBest

Hypertension and insulin resistance frequently occur together as part of the dysmetabolic syndrome.

The addition of hypertension to the clinical picture of diabetes amplifies the already high cardiovascular disease risk in these patients.

Aggressive blood pressure control prevents more cardiovascular events in diabetics than non-diabetics.

Diagnosis CriteriaDiagnosis Criteria

One test is not enough!One test is not enough! The diagnosis must be done by a physician.The diagnosis must be done by a physician.

NormalNormal Pre Pre diabetesdiabetes

DiabetesDiabetes

Fasting Blood Glucose Fasting Blood Glucose Test (FBG)*Test (FBG)*

Less thanLess than100100

Between Between 100 - 125100 - 125

More than or More than or equalequal

to to 126126

Glucose Tolerance Test Glucose Tolerance Test (GTT) **(GTT) **

Less thanLess than 140140

Equal to or more Equal to or more than than 140140 but but

less than less than 200200

More than or More than or equal to equal to 200200

* FBG blood test is done after fasting 8 hours.

** GTT results are repeated after 2 hours. A person drinks a 75 mg glucose solution before test. 100 mg for Pregnant women.

Retinopathy: 25x

Complications of DiabetesComplications of Diabetes

End-Stage Kidney Disease: 17x

Heart Disease: 2-4x

Foot/Leg Amputations:

5x

Stroke: 2-6x

The Appropriate Blood pressure Control in Diabetes (ABCD) trial investigated the effect of aggressive blood pressure control in type 2 diabetic patients with peripheral arterial disease.

The intensively treated group (125/75 mm Hg) had no increased risk of cardiovascular events over 4 years of follow up.

Achieving American diabetes association target blood pressure (130/80 mm Hg) almost always requires more then one agent.

Hypertension and diabetes being two important risk factors for cardiovascular disease, stroke and chronic kidney disease deserve prime importance in strategy for control of non-communicable diseases.

In the united kingdom prospective diabetes study (UKPDS), each 10 mmHg decrease in mean systolic blood pressure was associated with -----

reduction in risk of 12% for any complication related to diabetes.

15% for deaths related to diabetes. 11% for myocardial infarction.13% for micro vascular complications.

But treatment of hypertension in diabetes mellitus is not always easy and much confusion prevail regarding ------

Definition

Target blood pressure

Use of specific agents like ACE inhibitors, ARB, thiazide diuretics and beta-blockers and their adverse effects.

Definition, screening and diagnosisAccording to Joint National Committee – 7 (JNC-7)

Staging SBP DBPNormal <120 <80Prehypertensive 120-139 80-89Stage 1 hypertension 140-159 90-99Stage 2 hypertension >160 >100

In Prehypertensive-------Life style modification

Stage 1 & 2 Should be treated

But Prehypertensive + diabetes mellitus /CKDLife style modification,if it fails to redude BP to <130/80 mm Hg then---Start drug therapy

According to ADA

BP should be measured at every routine diabetes visit.

BP should be less than 130/80 mm Hg.

Orthostatic measurement of blood pressure should be performed to assess for the presence of autonomic neuropathy.

Certain special characteristics of hypertension in diabetes mellitus

Nocturnal hypertension in diabetes mellitus –

Lack of nocturnal dipping in arterial blood pressure has been demonstrated both in type 1 and type 2 diabetes.

The lack of nocturnal dipping is associated with increased risk of stroke and myocardial infarction.

Night time BP control becomes especially important in diabetics.

Excessive salt sensitivity and increased extracellular volume:

BP of diabetic patients is more sensitive to salt intake and this sodium sensitivity is found even in absence of nephropathy.

A decreased salt intake is important for diabetic patients with hypertension.

Diabetes ,hypertension and nephropathy---

Increased systolic BP is a significant risk factor for micro albuminuria and rapid progression of nephropathy.

Isolated systolic hypertension-----

ISH is strongly related to development of micro and macrovascular diseases in patients with DM.

Goals of therapy----

American Diabetes Association recommends target blood pressure levels of <130/80 mm Hg.

In pregnant patients with diabetes and chronic hypertension, blood pressure target goals of 110-129/65-79mm Hg are suggested in the interest of long term maternal health and minimizing impaired fetal growth.

Non-pharmacological management of hypertension in

diabetes

Weight loss Loss of weight by 1kg decreases BP by approx 1mm hg.Sodium restrictionDecrease in sodium intake from 4.6 gm to 2.3 gm/day results in reduction of 5mm Hg is SBP and 2-3 mm Hg in DBP.Exercise Diabetic patients who are 35 yrs of age or older and are planning to begin a vigorous exercise programme should have exercise stress testing or other appropriate non-invasive testing.At least 150 min of moderate intensity aerobic physical activity is recommended per week.Smoking cessationModeration of alcohol intake.

HealthHealth

Physical ActivityPhysical Activity

++

Sound NutritionSound Nutrition

Good HealthGood Health

HealthHealthThe first part of our The first part of our

equation is activityequation is activityGet moving, find something you Get moving, find something you

enjoyenjoy

HealthHealthThe second part of the The second part of the

equation is nutritionequation is nutrition Your body needs the right fuel to help it Your body needs the right fuel to help it

work well. work well.

The ADA PyramidSIX FOOD GROUPS:•Group 1: Bread, grains and other starches•Group 2: Vegetables•Group 3: Fruits•Group 4: Milk •Group 5: Meats, meat substitutes and other proteins(like cheese, eggs, tofu). •Group 6: Fats, oils and sweets

Encourage people to change habits.

Use the pyramid guide to educate people to eat healthy.

Pharmacological therapy

General principles of treatment ---

It has been recommended that all patients should receive either an ACE inhibitor or ARB.

Multiple drug therapy is generally required to achieve target blood pressure.

Aspirin therapy is recommended in patients of diabetes with hypertension.

(ADA position statement diabetes care 30:54-541, 2007)

Statin therapy should be given to achieve LDL cholesterol level <100 mg/dl.

Pharmacological therapyThiazide diuretic and Beta Blockers- There have been concerns among physicians as many studies have shown thiazides and beta blockers promote glucose intolerance.Inspite of this both agents have been recommended for treatment of hypertension in DM, lower doses of shorter acting thiazides- hydrochlorthiazide instead of chlorethalidone are generally well tolerated and not associated with adverse metabolic effects. Recommendations for beta blockers are-- combined alpha and beta blocker should be preferable agents. Carvedilol is the potential agent of choice as it effectively control blood pressure and improves insulin sensitivity and decreases HbA1C.

ACE inhibitors

Reduce cardiovascular mortality and progression of renal disease.

Increases upto 30-35% from baseline serum creatinine level (creatinine of 3mg/dl or less) that stablize with in the first 2 months of ACE inhibitors therapy should not deter use of these agents.(Arch Intern Med 2000).

combination of ACE inhibitors and ARBs causes dual blockade of RAS and provides superior renoprotection but serum potassium level should be monitored causitiously.

The UKPDS and systolic hypertension in Europe trial (Syst-Eur) have shown beneficial effects for both ACE inhibitors and calcium channel blockers in patients with diabetes.

Modulation of the renin angiotensin system has particular importance in diabetic patients.

ACE inhibitors reduces nephropathy and end stage renal disease in patients with type 1 diabetes, and angiotensin receptor blockers reduce the risk of these microvascular disorders in patient with type 2 diabetes.

In the Heart Outcomes and Prevention Evaluation (HOPE) study, ramipril significantly decreased the rates of myocardial infarction ,stroke and death in patients with diabetes and a mean blood pressure of 140/80 mm Hg.

The Losartan Intervention For End point (LIFE) study enrolled 1195 diabetic subjects as part of the cohort. Participants had hypertension and evidence of left ventricular hypertrophy, subjects were randomized to losartan or atenolol. Despite equivalent blood pressure lowering, the subjects randomized to losartan experienced a 39 percent reduction in all cause mortality, a 37 percent reduction in cardiovascular mortality, and a 21 percent reduction in stroke.

Calcium channel blockers

Amlodipine

Modified release nifedipine can be used.

Treatment Program for Patients with Hypertension and Diabetes

How Can You Help How Can You Help ReduceReduce Your Risk of Your Risk of Hypertension in Hypertension in DiabetesDiabetes??

Eat foods

low in

fat &

calories.

If overweight

,lose weight.

Physical activity

Stop smoking!

Limit alcohol to 1-2 drinks per day.

Take your medications regularly.

What are goals to healthy What are goals to healthy living?living?

BeBe SMART SMART

SSpecificpecific MMeasurableeasurable

AAchievablechievableRRelevantelevant TTimeime

SummarySummary

Diabetes is a growing problemDiabetes is a growing problem Hypertension is a growing problemHypertension is a growing problem Hypertension and diabetes are dying Hypertension and diabetes are dying

problemsproblems Hypertension is preventableHypertension is preventable