Blood Pressure and DiabetesBlood Pressure and Diabetes

Colin M. Dayan

University of Bristol/UBHT

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Geiss LS, et al. In: Diabetes in America. National Institutes of Health;1995.

Causes of Death in Causes of Death in People With DiabetesPeople With Diabetes

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Any diabetes-related endpointsAny diabetes-related endpoints

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10%

20%

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40%

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0 3 6 9

% o

f pat

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ith e

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Years from randomisation

Tight blood pressure control (758)

Less tight blood pressure control (390)

risk reduction24% p=0.0046

Benefits of Tight BP and Tight Glucose Benefits of Tight BP and Tight Glucose Control Control UKPDSUKPDS

-50

-40

-30

-20

-10

0

Tight glucose controlTight BP control

Microvascularendpoints

*

StrokeAny diabetes-

related endpointDiabetes-related

deaths

*

*

*

*P<0.02, tight BP control (achieved BP 144/82 mm Hg) vs.. less tight control (achieved BP 154/87 mm Hg).†P<0.03, intensive glucose control (achieved HbA1c 7.0%) vs. less intensive control (achieved HbA1c 7.9%).UKPDS Group. BMJ. 1998;317:703-713.UKPDS Group. Lancet. 1998;352:837-853.

Risk reduction

(%)

†

†

Case 1Case 1

• 61 yr old man• Type 2 diabetes diagnosed last year• Albumin/creatinine ratio = 13.5• Creatinine = 103• BP = 155/90• Cholesterol = 5.5• HbA1c = 7.2% on Metformin

Trea t A L L ris k fac to rsB P < 1 3 0 /7 5 , A S A s ta tin , H b A 1 c

E xc lu d e in fec tion (M S U )

P os it ive - d o n o t sc reen fo r m ic roa lb

Trea t A L L ris k fac to rs

> 3 on 2 /3 occas ion s= m ic roa lb u m in u ria

R esu m e an n u a l s c reen in g

> 3 on less th an 2 /s occas ion s

N eg ative - sen d a lb /c rea t(id ea lly firs t am )

D ip s tic k tes t fo r p ro te inTyp e t it le h e re

European Guidelines on European Guidelines on hypertension in T2DM 2002hypertension in T2DM 2002

• Review BP if single reading >140/85 (130/75 if microalb)

• Consider HBPM or ABPM (cut-off ?130/75) 12-20/8-12mmHg less.

• Address all CV risk factors - statin, ASA• NB Statins also reduce microalb excretion• Target 140/85 • Drugs

European Guidelines on European Guidelines on hypertension in T2DM 2002 - hypertension in T2DM 2002 -

DrugsDrugs• Nephropathy - ACE, A2RA, CCBs,

indapamide• Hyperkalaemia - Loop diuretics or thiazides• Angina - Beta block or CCB• MI or LV dsyfunction - beta block and ACE• ISH - thiazides and CCBs• Not alpha blockers as first line• Use once daily dosing to aid compliance

HbAHbA1c1c cross-sectional, median values

06

7

8

9

0 3 6 9 12 15

HbA

1c (

%)

Years from randomisation

Conventional

Intensive

6.2% upper limit of normal range

Blood Pressure : Tight vs Less Tight Blood Pressure : Tight vs Less Tight Control Control

60

80

100

140

160

180

0 2 4 6 8

mm

Hg

Years from randomisation

cohort, median values

Less tight control Tight control

Bristol Integrated Care Bristol Integrated Care PathwayPathway

• 140/80• In the presence of nephropathy: 135/75 or

lower.

Bristol Integrated Care Bristol Integrated Care PathwayPathway

• Step 1 Lifestyle• Step 2 ACE (or A2RA if cough)• Step 3 Diuretic (BFZ, Frusemide)• Step 4 beta blocker

PANDIPP

Case 2Case 2

• 69 yr old woman with Type 2 diabetes diagnosed 7 years ago

• BMI = 33• Proteinuria ++ on 3 occasions• BP = 160/95• Creatinine = 135• K+ = 5.9• HbA1c = 9.0% on Glibenclamide and Metformin

Case 3Case 3

• 28 yr old woman with Type 1 diabetes since age 12

• Retinopathy - laser 2 years ago• BP = 144/88• Alb/creat = 5.4• HbA1c = 10.1%• Cholesterol = 5.3

Perkins, B. A. et al. N Engl J Med 2003;348:2285-2293

Microalbuminuria can disappear in 58% of cases

Case 4Case 4

• 74 yr old man with T2DM diagnosed 4 years ago

• BP = 140/80• Proteinuria + on 2 occasions• Cholesterol = 4.9• HbA1c = 7.3%

The British Hypertension Society recommendations for combining The British Hypertension Society recommendations for combining Blood Pressure Lowering drugsBlood Pressure Lowering drugs

Younger (e.g.<55yr)and Non-Black

Older (e.g.55yr) or Black

Step 1

Step 2

Step 3

Step 4Resistant Hypertension

Add: either -blocker or spironolactone or other diuretic

A: ACE Inhibitor or angiotensin receptor blocker B: - blockerC: Calcium Channel Blocker D: Diuretic (thiazide)

A (or B)

A

A or B C or D

C or D +

+ +C D

Adapted from : ‘Better blood pressure control: how to combine drugs’Journal of Human Hypertension (2003) 17, 81-86

Treating Hypertension in Treating Hypertension in NephropathyNephropathy

Lewis et al 2001

Is home blood pressure Is home blood pressure monitoring useful?monitoring useful?

Home BP vs clinic BPHome BP vs clinic BP