Diabetes and hypertension frequently occur together and amplify cardiovascular risk. Aggressive blood pressure control is especially important for diabetics to prevent events like heart disease and stroke. The document discusses the history of diabetes and hypertension, complications, diagnosis criteria, treatment goals, and pharmacological and lifestyle approaches to managing hypertension in diabetes. The key goals are achieving a blood pressure under 130/80 mmHg through lifestyle changes and often multiple drug classes like ACE inhibitors or ARBs to protect the kidneys and reduce cardiovascular risk.

1. Management of Hypertension
in Diabetes
Dr. Awadhesh Kumar
Sharma

3. Diabetes: 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).

4. Diabetes: History

1500 B.C.-Earliest known
record of diabetes
mentioned on 3rd Dynasty
Egyptian papyrus by
physician Hesy-Ra;
mentions polyuria as a
symptom.
400 B.C.-Indian surgeon
Susruta describes ‘honeyed
urines’ produced by ‘big
eaters of rice and sugar’.

5. Diabetes: History

250 A.D.-Apollinius of Memphis
coins the name ‘diabetes’

1674-Thomas Willis publishes ‘The
Diabetes or Pissing Evil’. Writes
‘those laboring with this Disease,
piss a great deal more than they
drink’ asserting that all diabetic
urine ‘was wonderfully sweet as if it
were imbued with Honey or Sugar’

6. Diabetes: History




1798- John Rollo documents excess sugar in blood
and urine
1813- Claude Bernard links diabetes with glycogen
metabolism
1869- Paul Langerhans (German medical student)
finds islets in the pancreas, but is unable to explain
function
1889- von Mehring and Minkowski prove that
diabetes develops when they remove the pancreas
of dogs

7. Diabetes: History

1910- English physiologist, Sir
Edward Albert Sharpey-Schafer,
suggested that a single chemical
component was missing from the
pancreas of diabetics and called it
“insulin”.

1922- Banting and Best (a medical
student) isolate insulin (‘ilsetin’ or
‘iletin’) and inject the ‘thick brown
muck’ into a 14 year old boy (7.5
ml into each buttock) producing
some fall in glucose complicated
by abscesses

8. 
Diabetes: History
1922- Collip refines the extract and reinjects it in the boy with glucose falling
from 520 to 120 mg/dl in 24 hours

9. Diabetes: History
Banting
Macleod
Best
Collip

10.  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.

11. Diagnosis Criteria
Normal
Pre diabetes
Diabetes
Fasting Blood Glucose Test
(FBG)*
Less than
100
Between
100 - 125
More than or equal
to 126
Glucose Tolerance Test
(GTT) **
Less than
140
Equal to or more than
140 but
less than 200
More than or equal
to 200
* 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.


One test is not enough!
The diagnosis must be done by a physician.

12. Complications of Diabetes
End-Stage Kidney
Disease: 17x
Stroke: 2-6x
Retinopathy: 25x
Foot/Leg
Amputations:
5x
Heart Disease: 2-4x

13. 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.

14. 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.

15. 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.

16. Definition, screening and diagnosis
According to Joint National Committee – 7 (JNC-7)
Staging
Normal
Prehypertensive
Stage 1 hypertension
Stage 2 hypertension
SBP
<120
120-139
140-159
>160
DBP
<80
80-89
90-99
>100

17. In
Prehypertensive------Life style modification
Stage 1 & 2
Should be treated
But Prehypertensive + diabetes mellitus /CKD
Life style modification,if it fails to redude BP to <130/80
mm Hg then--Start drug therapy

18. 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.

19. Certain special characteristics of
hypertension in diabetes mellitus

20. 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.

21. 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.

22. 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.

23. 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 110129/65-79mm Hg are suggested in the interest of
long term maternal health and minimizing impaired
fetal growth.

24. Non-pharmacological
management of
hypertension in
diabetes

25. Weight loss
Loss of weight by 1kg decreases BP by approx 1mm hg.
Sodium restriction
Decrease 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 noninvasive testing.
At least 150 min of moderate intensity aerobic physical
activity is recommended per week.
Smoking cessation
Moderation of alcohol intake.

27. Health
Physical Activity
+
Sound Nutrition
Good Health

28. Health
The first part of our
equation is activity
Get moving, find something you
enjoy

30. Health
The second part of the
equation is nutrition
Your body needs the right fuel to help it
work well.

31. The ADA Pyramid
SIX 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

32. Encourage
people to
change
habits.
Use the pyramid guide to educate people to eat healthy.

33. Pharmacological therapy

34. 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 30:54541, 2007)
Statin therapy should be given to achieve LDL
cholesterol level <100 mg/dl.

35. Pharmacological therapy
Thiazide 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.

36. 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.

37. 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.

38.  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.

39. Calcium channel blockers
Amlodipine
Modified release nifedipine can be used.

40. Treatment Program for Patients with
Hypertension and Diabetes

41. How Can You Help Reduce Your Risk of
Hypertension in Diabetes?
Limit alcohol to
1-2 drinks
per day.
Take your
medications
regularly.
Stop sm
oking!
If
ove
r we
igh
l os e
w e i t,
ght
.
 Phy
sical
activ
ity
ow
ds l
foo
Eat
s.
lorie
in
ca
t &
fa

42. What are goals to healthy
living?
Be SMART
Specific
Measurable
Achievable
Relevant
Time

43. Summary
 Diabetes is a growing problem
 Hypertension is a growing problem
 Hypertension and diabetes are dying
problems
 Hypertension is preventable